International Food Security and Public Health: Supporting Initiatives and Actions

Abstract
Since 2000, progress has been made toward the reduction of world hunger, malnutrition, and extreme poverty. However, such progress is neither universal nor equitable across regions and subregions. Hunger remains an everyday challenge for more than 815 million people worldwide, including 780 million residents of developing regions who are chronically undernourished. In addition to the day-to-day hunger experienced by so many, over 2 billion people worldwide are micronutrient deficient, and more than 150 million children younger than 5 years are stunted due to malnutrition. Efforts to feed the hungry and undernourished and to ensure food security are impeded by a host of factors including urbanization, limited educational opportunities, internal and transnational migration, flawed agricultural policies, water scarcity, the effects of climate change, and violent conflicts. Even when overall national food supplies are sufficient, inequitable distribution systems can limit access for many segments of the population, and gender norms and household feeding practices contribute to food insecurity at both the household and individual levels. Hunger, poverty, and disease are interlinked, underscoring that hunger eradication should remain a key commitment for decision makers at all political levels. To that end, world governments and international food and nutrition organizations should dedicate appropriate funding and resources to improve international food security and achieve a healthy, equitable, and sustainable food system that benefits all.

Relationship to Existing APHA Policy Statements
This policy builds upon and replaces Policy Statements 6522 (Nutritive Value of Food Distributed Abroad) and 20093 (Food Crises: Addressing the Current Crisis and Preventing the Next One). It is also consistent with or has relevance to the following APHA policy statements that address nutrition, food issues and health, and food systems:

• APHA Policy Statement 201512: Ensuring That Trade Agreements Promote Public Health
• APHA Policy Statement 20157: Public Health Opportunities to Address the Health Effects of Climate Change
• APHA Policy Statement 201113: Call to Action to Reduce Global Maternal, Neonatal and Child Morbidity and Mortality
• APHA Policy Statement 201111: Prioritizing Noncommunicable Disease Prevention and Treatment in Global Health
• APHA Policy Statement 20089: Strengthening Health Systems in Developing Countries
• APHA Policy Statement 200712: Toward a Healthy Sustainable Food System
• APHA Policy Statement 20058: Supporting the WHO Global Strategy on Diet, Physical Activity and Health

Problem Statement
APHA champions the health of all people, striving to improve health and well-being at the individual and population levels and to bring about the change needed to shape a more prosperous and sustainable future. International food security is critical to ensuring the health and productivity of the world’s people, to maintaining the economic viability and political stability of communities around the world, and to fulfilling a fundamental human rights principle that the guarantee of sufficient amounts of nutritious food can enable individuals to achieve a standard of living that will maximize their health and well-being.[1] Achieving food security continues to be a challenge. After almost two decades of decline, the number of chronically undernourished people in the world has begun to rise, largely because of increased conflict situations, climate-related shocks, and economic downturns.[2] APHA calls for a commitment to initiatives, policies, and programs that promote international food security, support for country-based food and nutrition surveillance activities, and the equitable distribution, supply, and accessibility of nutritious, adequate, and affordable food. 

Scope of the problem: Despite important gains over the past two decades in combating hunger, it remains an everyday challenge for more than 815 million people worldwide.[2] The majority are chronically undernourished people living in low- or middle-income countries in sub-Saharan Africa and southeastern and western Asia, with smaller numbers in Latin America and the Caribbean.[2,3] Certain groups are particularly vulnerable to food insecurity, including children younger than 5 years (and especially those younger than 3 years), pregnant and lactating women, migrants, older adults, and people living with HIV/AIDS. Fifty-two million children younger than 5 years suffer from wasting, and 155 million are stunted due to chronic malnutrition.[2] Given that undernutrition is a significant contributor to child mortality resulting from fetal growth restriction, stunting, wasting, micronutrient deficiencies, and suboptimal breastfeeding and child feeding practices, children in this age group are at especially high risk. Stunting is estimated to be an underlying cause of 45% of child mortality and anemia, largely owing to dietary deficiencies, which also contribute to 20% of maternal mortality.[3–5] Food insecurity among children may result in increased risks for hospitalizations, asthma, depression, suicide, and oral infections. In addition to the day-to-day hunger experienced by so many, more than 2 billion people worldwide are affected by micronutrient deficiencies, leading to premature death, poor health, blindness, stunting, reduced cognitive development, and low productive capacity.[4,5] Although a lengthier discussion is beyond the scope of this policy statement, it bears mentioning that household food insecurity is a persistent problem in high-income and upper-middle-income countries.[2] For example, in the United States alone, more than 41 million people experience food insecurity.[6]

Social dimensions of food security: Food security is achieved when all people, at all times, have physical and economic access to safe and nutritious food in sufficient amounts to meet their dietary needs and food preferences for an active and healthy life.[7] The World Food Programme identifies three elements that are essential to food security: availability, access, and utilization.[8] These tenets align closely with the four key components—availability, accessibility, adequacy, and sustainability—of the “right to food” advanced by the Office of the United Nations High Commissioner for Human Rights.[9] Food should be available in sufficient quantities and on a consistent basis from natural resources and for sale in local markets. People in any location must be able to have physical and economic access to the food they need in sufficient amounts, whether by home production, purchase, food aid, or other means. Food must satisfy nutritional needs based on an individual’s age, living conditions, gender, and occupation; also, it must be safe for human consumption and culturally acceptable.[8,9] In addition, food consumed must have a “positive nutritional impact” by providing not only adequate calories but also sufficient protein and micronutrients to counter malnutrition. Food should be accessible for current and future generations, and supplies should account for events that can disrupt the availability of food, such as wars, internal conflicts, and climatic events.[8]

Food security and social determinants of health: Food security is associated with the social determinants of health, which are “the conditions in which people are born, grow, live, work and age.”[10,11] Social determinants are typically the source of health inequities, or the “the unfair and avoidable differences in health status seen within and between countries.”[11] Food security in the context of social determinants of health is interconnected with population growth, political instability, economic development, urbanization, migration, agricultural policy, and environmental factors such as land use, water scarcity, and climate change. For example, worsening food security conditions and hunger are seen in areas of economic slowdown, civil strife, urbanization with limited markets or inadequate housing to prepare and store food, and diminishing food access due to rising domestic food prices or lower import capacity.[2] At the same time, food security is only one of several factors that can determine nutritional outcomes. Other such factors include women’s educational level; resources allocated to national policies and programs related to maternal, infant, and young child nutrition; access to clean water; explicit support for breastfeeding and timely introduction to appropriate weaning foods; basic sanitation and high-quality health services; lifestyles; the food environment; and culture.[2] 

Hunger, poverty, and disease are interlinked and are a direct result of the lack of a sustainable and accessible food supply.[12] People living in poverty often cannot produce or buy enough high-quality food to eat. As a result, they are frequently hungry, susceptible to widespread disease, and unable to work, resulting in lost labor productivity. Hunger is a major constraint to a country’s immediate and long-term economic, social, and political development.[12] With an anticipated world population of 9.5 billion people by 2050, attention must be given to food and agricultural production and sustainable food systems for people living in developing countries with anticipated growth. Such is the case for countries in Africa, where the population is expected to double by the year 2050, reaching 2.0 billion people. Another example is the increasing migration to urban areas, with more than 2.5 billion people in the developing world expected to reside in urban locales by 2050.[13,14] 

In addition to deeply entrenched poverty in many parts of the world, conflict and displacement, resulting in large-scale migration of populations attempting to escape violence, have caused international food security to diminish. For example, more than 100 million people faced crisis-level food insecurity in 2016, and more than 2 billion people live in areas disrupted by violent conflicts.[2] The majority of the world’s undernourished people are living in conflict settings. Moreover, “food insecurity itself can become a trigger for violence and instability” in places with “pervasive inequality and fragile institutions.”[2]

Climate change can undermine food availability, access, and stability by reducing the production of staple crops, increasing the prices of other crops, undermining dietary diversity, and causing fluctuations in food availability due to extreme weather events.[14] Severe weather events such as droughts are likely to increase in frequency as a result of climate change and to heighten the risk of conflicts over scarce resources in already-vulnerable regions. For example, much of the instability in Sudan can be directly linked to droughts and climate-driven weather fluctuations.[2] Continued use and expansion of unsustainable agricultural practices that fail to consider the impacts of climate change not only on food production but on well-being and health, especially in the most vulnerable parts of the world, will exacerbate the human costs of these events.[2] 

Political and ethical issues: Numerous international organizations, including the Office of the United Nations High Commissioner for Human Rights, the World Health Organization, and the Food and Agriculture Organization of the United Nations (FAO), recognize the human right to adequate nutritious food. According to the International Union of Nutritional Sciences, “To live a life without malnutrition is a human right. The persistence of malnutrition, especially among children and mothers in this world of plenty, is immoral. Nutrition improvement anywhere in the world is not a charity but a societal, household, and individual right.”[15] Several world initiatives have made progress toward achieving food security, reducing poverty, and developing the agricultural sector.[16] The world community committed to drastically reducing hunger in the Millennium Development Goals and the Sustainable Development Goals (SDGs).[17] SDG Goal 2, “to end hunger, achieve food security and improved nutrition, and promote sustainable agriculture by 2030,” focuses on improving food systems and nutrition, particularly among the poor and people in vulnerable situations and life stages.[17] Diplomatic missions designed to increase global food security with the collaboration of foreign governments, nongovernmental organizations, and others (i.e., charities) benefit more than 170 countries.[17]

The U.S. government has long played a role in alleviating global hunger and food insecurity through food aid programs, starting with aid to Europe after World War I and the Marshall Plan after World War II. Food assistance was expanded to other regions of the world in the Title II Food for Peace Act (1954). The Title II program (funded through fiscal year 2018 in the 2014 Farm Bill) was considered a way to distribute excess agricultural commodities from U.S. farmers while helping distressed countries become self-sufficient in food production. Over time, the program has expanded to include direct food relief in emergencies and the sale or donation of U.S. agricultural commodities on concessional terms to generate local currency and fund nutrition, agriculture, and other development programs. Direct cash transfers enabling vulnerable populations to purchase local food in emergencies have been introduced in recent years.[18,19] In the Title II program, the U.S. Department of Agriculture purchases commodities from U.S. farmers, while the U.S. Agency for International Development (USAID) administers the program.[20] 

The federal government has passed additional legislation, implemented policies, and entered into collaborative partnerships with other national governments to increase global food security and provide nutritional support to vulnerable populations, including mothers, small children, and people living with HIV and AIDS.[21] The Department of Agriculture funds several global food security programs, including the Global Agriculture and Food Security Program, a multilayered trust fund aimed at aiding 18 low-income countries and 8.2 million beneficiaries.[18] In 2016, the U.S. Congress passed the Global Food Security Act and made a commitment to ending poverty and hunger around the world.[19] Support for these and other U.S. food aid programs that go beyond food distribution by promoting health and nutrition and strengthening agricultural and income generation programs is crucial to U.S. efforts to improve food security at the international level.[19] While the U.S. government has made many major contributions to support food security, it has failed to adequately promote breastfeeding, the single most important factor supporting adequate infant and child nutrition; also, the federal government has not sufficiently advocated against the marketing of breast milk substitutes by the infant formula industry.[22] 

Evidence-Based Strategies to Address the Problem
The need to support and strengthen international policies related to health, climate change, and food security is compelling and requires ongoing collaboration and coordination to achieve political advantage, adequate funding, and accountability in the monitoring, production, and supply of safe food.[23,24] At the same time, more resources are needed for food supply monitoring and surveillance, as well as collection and interpretation of dietary data, to ensure a safe, adequate, and nutritious food supply at the local and regional levels.[23,24] 

The ability of the United States to support and strengthen policies related to climate change and food security is contingent on the president and Congress endorsing policies to mitigate climate change (including reaffirmation of the Paris Climate Agreement and its principles) and adequately funding the U.S. Environmental Protection Agency (EPA) and USAID. Historically, the EPA has documented the consequences of climate change for human health, agriculture, and food security and funded programs to help mitigate the impact of climate change. The continued need for such support is evidenced by peer-reviewed research showing that climate change will have strong negative effects on agriculture, health, and global food security.[24–26] The link between climate change and a broad range of threats to public health is further supported by improved scientific confidence, recognition of populations of concern, and identification of emerging health issues.[26]

USAID plays a critical role in stabilizing countries and building responsive local governance by investing in agriculture, health systems, and democratic institutions. Its efforts support country-driven approaches to development with input and collaboration from local organizations and leaders, local farmers and landowners, and their families. Specific to food and nutrition efforts, USAID uses a comprehensive approach to fight hunger and strengthen food security. It invests in agricultural research to improve food production; assists farmers with marketing, resources, and training; develops sustainable agriculture strategies; and provides emergency food assistance to vulnerable and malnourished populations in times of crisis.[27] 

The argument that the U.S. president should sign and/or the U.S. Senate should ratify relevant United Nations Conventions supporting international food security is evidenced by UN conventions, including the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW), that promote adequate nutrition and food security. CEDAW stipulates that women should have equal access to education, employment, and health care, all of which contribute to food security.[28,29] As specifically noted in the UN Convention on the Rights of the Child, nutrition “should be regarded as a fundamental human right.”[30]

The involvement of the U.S. government, foundations, and other donors in expanding and coordinating support for improved nutrition is critical to initiatives such as Feed the Future, Scaling Up Nutrition, and the First 1,000 Days Partnership that highlight the need for an integrative cross-sectoral response among government, organizational, and donor entities that is effectively coordinated toward achieving substantive improvements in nutrition.[3,31–33] Of importance to sustainability efforts in this regard is increased funding to support grassroots and local initiatives. In one successful partnership, the Peace Corps and USAID are working within the Global Food Security Framework Agreement to support food security programming. However, whether Peace Corps or similar programs (e.g., programs in which women’s groups grow vegetables to improve their livelihood or school gardens are used to increase student intake of nutritious vegetables) are successful in achieving food security in the long term is unclear. While urban agriculture may contribute to improved food security in low- or middle-income countries, the fact that impact evaluations are absent from the current evidence reveals a need for increased efforts to conduct rigorous evaluations and provide funding to support such programs.[34] 

Governmental agencies and multistakeholder partnerships have been shown to be important facilitators in improving nutrition in developing countries and achieving the SDGs.[35] However, the private sector is increasingly interested in and supportive of addressing undernutrition, and nongovernmental and civil society groups are engaged in nutrition advocacy and education.[33,35] This situation is creating key opportunities to increase funding and develop new partnerships by engaging the private sector in nutrition improvement efforts as well as efforts to improve access to markets and the supply chain.[35] Civil society organizations can contribute by delivering nutrition interventions to consumers, promoting behavioral change–related communications, and holding governments and private-sector organizations accountable.[33] While there is an interest in undernutrition and food security in all sectors, continued coordination efforts are required to identify new sources of funding and partnerships.[33,35] 

It is relevant to food security, agricultural, and nutrition programs and policies for the U.S. government and food and nutrition organizations to provide resources that support global efforts to collect and interpret dietary data.[36–38] It is difficult at present to compare diets across cultures, geographies, or time periods. This has hampered a global consensus on what constitutes a nutritious diet. The 2013 Lancet Series on Maternal and Child Nutrition and the 2016 Global Nutrition Report specifically highlighted the need for sound and timely data to address undernutrition, changing dietary patterns, and fortification and to better coordinate and improve nutrition programs and their implementation.[39] Despite the recognized need for improved dietary data related to intake of food and nutrients, the patterns and distributions of intake of key foods around the world are not well established. Most global analyses have relied on crude national estimates of FAO food balance sheets.[40] However, these estimates do not accurately reflect individual dietary intake, nor do they distinguish within populations or among individuals by age or gender; thus, their usefulness is limited.[41] Of concern is the limited data for sub-Saharan African countries, given that such data often overestimate individual-based levels of dietary intake, do not account for gender and age consumption disparities within households (among men, women, and children), and do not reflect changing dietary patterns and consumption of processed foods across Africa and Asia as populations move to more urban areas.[36] 

There are ongoing challenges related to collecting consistent data across countries and how these data are used for dietary and food security assessments. Efforts are under way to help alleviate these issues, but there remains a need for adequate resources and ongoing research support. In one relevant effort, the Global Nutrition and Policy Consortium is collecting and evaluating dietary data from countries worldwide and then translating these data into policies and interventions designed to improve global health, particularly in poor and vulnerable populations.[42] 

To ensure high-quality data on food and nutrient consumption, world governments and food and nutrition organizations should be involved in food supply surveillance and collection, generation, and interpretation of dietary data; also, they should engage in efforts to improve survey implementation, assessments, and outreach capacities.[36] These data can be used to establish relationships between consumer food choices and health outcomes with the aims of designing and evaluating food fortification programs, monitoring food safety, and tracking shifting consumption patterns.[38,41] Individual intake dietary data and age- and gender-specific dietary data are needed to develop population-appropriate dietary guidelines and food labels. While there are well-established methods for collecting individual-level dietary data (e.g., 24-hour dietary recalls and food frequency questionnaires), large-scale collection of dietary data in low-income countries (and within countries) is limited and often problematic. In such countries, there are typically country-specific and often region-specific requirements for food composition data as well as constraints to data collection.[36,41,43] As a result, food and nutrition policies may be developed without the benefit of relevant data or evidence-based research findings. In addition to means of collecting and assessing dietary data, barriers persist related to funding, relevant training, and investment in the research infrastructure needed to enhance and standardize the data collection process.[38]

Two efforts to address data collection via survey implementation that are of potential interest to the global nutrition community are the International Dietary Data Expansion (INDDEX) project and GloboDiet.[38,43] The INDDEX project is a mobile application designed to collect individual-level dietary data using 24-hour recalls with a link to a Web database application that houses country- and region-specific inputs.[38] GloboDiet, a 24-hour dietary recall research tool tested and validated by the International Agency for Research on Cancer, is a component of the Global Nutrition Surveillance Initiative; validated in Europe, it is a potential common methodology for research and surveillance across Africa.[43] These and other efforts are promising but require the support of the global nutrition community to commit significant investments and resources for methodology improvements, adaptation and use of tools and economic models, implementation of findings, and enhanced research capacities.[1,38,43] 

Opposing Arguments/Evidence
Several scholars have put forth arguments against international food aid. These arguments include exacerbation of civil conflicts and cultural, health, economic, and environmental concerns. For example, Nunn and Qian suggest that U.S. foreign food aid can prolong civil conflicts; they note that theft of food aid and informal “taxation” by armed factions for transportation of food aid provide a source of income for internal warring parties.[44] Also, Nunn and Qian, along with Clapp, raise cultural and health concerns about international food aid.[45,46] According to these authors, some evidence suggests that U.S. international food aid continues to be driven by a surplus in domestic production, with a concomitant disregard for nutritional value and local preferences.[45,46] Clapp explicates additional health concerns, especially those raised by the European Union (EU), regarding U.S. international food aid.[46] While the EU rejects genetically modified organism (GMO) agricultural imports and has concerns about the long-term effects of GMO foods on health, the United States donates GMO foods to hungry countries. Clapp notes that, despite ongoing health concerns, recipient countries have no choice but to accept GMO foods from the United States to feed their people, raising ethical questions related to food safety in recipient countries.[46] 

These are valid points, and the United States and the EU do have different standards for GMO foods. However, the World Health Organization has declared that currently available GMO foods “are not likely to present risks to human health” and that there is no documentation of any negative health impacts on humans due to consumption of GMO foods.[47]

Concerns about the negative economic effects of international food aid have been raised specifically for African countries, but not recently. Lind and Teriessa concluded that international food aid has built a culture of dependency in countries such as Ethiopia and stymied local economic development and production.[48] It is worth noting, however, that others have concluded there is no correlation between international food aid and dependency. Little found that local farmers did not change their agricultural practices or production goals, did not rely on food aid, and continued to strive to meet their family’s food needs because the timing and amount of international food aid were so unreliable.[49] 

While Nunn and Qian found that foreign food aid can lengthen civil conflicts, their study was limited and did not address food aid provided in response to famines, natural disasters, and other humanitarian crises. Furthermore, research related to dependency, food aid driven by U.S. surplus production, and donations of nutrient-poor foods is limited and/or dated. Enacted in 2014, the Food for Peace Act, including the Bellmon Amendment, requires U.S. agencies providing international food aid to document that the food will not cause economic harm to local markets and to ensure that the food is nutritious. In addition, the Food for Peace Act aims to prevent conflicts around the world by enhancing global food security.[50]

Food aid contingent on large-scale industrialization has the potential to increase environmental degradation as well as undermine the ability of poor countries to produce food. Environmental challenges that food producers face (and may contribute to) include “soil erosion, desertification, climate change, the introduction and proliferation of non-native species and diseases, loss of biodiversity and reduced crop genetic diversity.”[51] Such adverse environmental conditions, in turn, disproportionally affect the world’s poorest countries and their ability to produce and harvest food given that they are not part of a sustainable food system.[51] 

These are valid points, and environmental concerns related to large-scale agricultural practices are beyond the scope of this policy statement. However, the action steps outlined below seek to address this issue as mitigating climate change has the potential to enhance food security for communities around the world.

Action Steps
Based on the evidence, there is a need for organizations such as APHA to support actions that strengthen policies and allocate adequate funding and resources to confront challenges related to food insecurity. Such actions include implementing U.S. policies that ensure adequate funding of agencies to improve international food security, support sound nutrition strategies, mitigate climate change effects on world food production, and support collaborative efforts of international food and nutrition organizations to improve food security. In addition, investment in small-scale farmers and agricultural enterprises around the world is necessary to facilitate long-term production of local and regional foods, to ensure local sovereignty over food production, and to increase access to agricultural markets for the poor, especially women. Ultimately, this amounts to investing in efforts to reduce the need for international food aid. 

APHA proposes the following action steps:

• The U.S. president and U.S. Congress should support and strengthen policies and funding of the EPA for prevention and mitigation of climate change effects on world food production, including reconfirming commitment to the Paris Climate Agreement and its principles.
• The president and Congress should ensure adequate funding for USAID programs that improve food security.
• The president should sign and/or the U.S. Senate should ratify relevant United Nations conventions that support global food security, including the Convention on the Rights of the Child, the UN Resolution to Support Breastfeeding, and the Convention on the Elimination of All Forms of Discrimination against Women. To be ratified, UN conventions must be signed by the president and then voted on by the Senate. As of 2018, the United States had not ratified CEDAW, which advocates for women’s basic human rights and supports food security and adequate nutrition for women worldwide. Also, the United States had not ratified the Convention on the Rights of the Child, which supports the right to adequate food for children worldwide.
• The U.S. government, foundations, and other donors should mobilize funding and resources to coordinate support from across society to increase the scale, scope, and impact of global efforts to improve food security and nutrition.
• The U.S. government should support (and fund) the development and mobilization of localized food security movements around the world.
• The U.S. government should dedicate resources to and support the initiation of a system to collect and interpret global dietary data.
• Food security stakeholders and the international food and nutrition community should improve capacities, practices, and coordination around data monitoring, data analysis, and information sharing within and across agencies.
• World governments and international food and nutrition organizations should promote mutual learning and collective accountability for achieving international food security.
• World governments and international food and nutrition organizations should support investments in the long-term production of local and regional foods to ensure local sovereignty over food production and increase access to agricultural markets for the poor.

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