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Jessamy: Hello and welcome to another episode of The Lancet Voice. I'm Jessamy Bagenal. 

Gavin: And I'm Gavin Cleaver. On today's show, we're talking about the grim problem of worldwide malnutrition, with the effects of COVID 19 potentially doubling the number of people worldwide in acute food insecurity, according to Dr.

Saskia Ossendorp, who I'll be speaking with later on. 

Jessamy: But first of all, we wanted to discuss dementia. I'm not sure whether we wanted to, but we felt that we should discuss dementia and how life events and choices can alter the risk of dementia. A recent update to our research on dementia added three new risk factors for dementia, making 12 total modifiable risk factors, which can account for 40 percent of dementia cases.

I spoke with Professor Jill Livingston of the University of College London about dementia and lifestyle. Jill, thanks so much for joining us today. And perhaps you could just start by telling us a little bit about what your background is and what your role is at the 

Gill: moment. I'm a psychiatrist by training and by profession.

I've been talking to patients before I talk to you today. And I work academically at University College London where I'm Professor of Psychiatry of Old Age and Head of Department of Mental Health Care of Old Age. Clinically, I work in Camden and Islington Memory Clinic so I'm very much involved in the dementia field, both clinically and academically.

Jessamy: I'm just going to read the opening sentence to the commission because I found it so striking and that's that worldwide around 50 million people live with dementia and this number is projected to increase to 152 million by 2050, rising particularly in low and middle income countries where around two thirds of people with dementia live.

So are dementia rates going up, or are we just having more people live longer? 

Gill: Really, more people live longer. So there are more people with dementia, but in fact, in Europe and America, there's consistent evidence that the incidence rates are decreasing. So there will be less people per thousand older people with dementia, but many more people with dementia.

And one thing That's good news. It means people are living to the old age, but we'd like them to live to the old age and fewer people have dementia. So that's, we're glad they're living. 

Jessamy: Yeah. Aren't we all, but yeah, good to have less dementia. Definitely. Yeah. Maybe you could just tell us what's changed since the 2017 commission on dementia.

Gill: One of the big things I think is in prevention, there's been more and more evidence about prevention since the 2017 commission. One of the things that I noticed is that when we launched the 2017 commission, there were quite a lot of people saying you can't prevent dementia, it's completely ridiculous.

There's few people saying that now. change in attitude with people beginning to understand that you really can make a difference. So I think that the ground is much more fertile and people are much more interested and willing to listen now about it. In terms of one of the things we said in 2017, which surprised everybody, surprised us really quite a lot, was that the most important risk factor was hearing.

We didn't expect that. We did systematic reviews and calculated, it came out. So one of the things that's happened since then is a lot of people have done research. In this field and there's been several studies which have looked naturalistically and I think a really hopeful thing that we didn't know before was that the people who use hearing aids and who have hearing impairment do not have an increased rate of dementia and that's really hopeful.

I know that these are not randomised controlled trials so it may be that People who use hearing aids are those people who are much better at looking after their health. It may not be in a randomised controlled trial that we see the same, but I think it, it's clear that if the people who use hearing aids don't develop dementia any more than everybody else in the population that the relationship between hearing and loss and dementia is not that of, that they're the same illness showing at different times.

And it looks. likely that giving hearing aids and encouraging people to use them and making them easier to use might be a relatively simple way to prevent a lot of people developing dementia. So that's a really good thing and a really important thing. 

Jessamy: Yeah, that's a fantastic aspect of it and that kind of just seems like a really easy intervention almost, particularly in high income countries that could be used.

Gill: Sorry, go on. You asked me, I've got lots of things that have changed, but you go on to the next thing. No, I don't want to. I want to hear more about them. You tell me. Okay. So another thing that's changed is the evidence about high blood pressure. And the level in which we would be trying to get people's blood pressure down to, which is now less than 130 and possibly less than 120, instead of the usual systolic of 140.

And the evidence that really can make a difference. These are randomized controlled trials, but every trial which usually has cognition and dementia as a secondary outcome rather than a primary outcome is abandoned because that anybody, even the sprint trial, which one group with 100 was supposed to be less than 140 and one less than 120 had to be abandoned because those are at 120.

had so much lower blood, had so much lower rates of strokes and death. But following up people after that years later, and we don't know what their blood pressure was, but it had been lowered. There was a significantly lower risk of mild cognitive impairment and mild cognitive impairment and dementia together.

That's really hopeful and helpful. So that's a second. thing. There is much more evidence, and this is why we added them, about different risk factors. So we were able to add different risk factors like alcohol and head injury. And so we added risk factors, and that Working that together, that made an increase in the number of potentially preventable dementia, and that's exciting in itself, that 40 percent potentially preventable.

We, for the first time, analyzed low and middle income countries, and as you mentioned, There are more people having with dementia in low and middle income countries and high income countries. I don't expect that, but it's the case, and what we were able to see was that there are more preventable dementias in low and middle income countries than in high income countries, and I think that's really exciting that's work that hasn't really started, and a lot of that could be done, so that's a really big move forward.

We also thought a lot more about physical health incorporating new evidence and they're much more tightly bound together dementia and physical health. So if you have very severe physical health, you develop dementia with less neuropathology and Therefore, and you develop worse dementia with less neuropathology, and while people's health should be looked after just for itself, trying to help people's physical health with dementia and trying to keep them well should reduce deterioration and might even possibly be another way into trying to reduce dementia in late life.

Jessamy: That figure of 40 percent being, potentially things that you can implement change in to reduce people's risks and to prevent dementia is amazing. I just wanted to talk more about these three extra kind of modifiable factors that you'd added in of alcohol consumption, air pollution and traumatic brain injury.

And I guess just in terms of patients thinking, what is the safe level of air pollution? What is the safe level of alcohol consumption to which you can say I'm modifying my risk for dementia. What is the evidence around that and where are the kind of cutoffs or do we not know?

We 

Gill: know about alcohol, that if you compare people who Who drink more than 21 units a week which in American is 14 drinks, and compared to people who drink less than 14 units a week, then the rate of dementia is increased. So we've really got a cut point. I don't think we're at the stage yet when we have a cut point with pollution.

We're very much in the more pollution is more bad for you area. We looked at all the pollution studies with for both cognitive impairment and dementia and systematically reviewed them. And all of them were consistent that pollution makes you more likely to develop dementia and that's interesting in itself.

Now you may think, and I certainly think, that being in a heavily polluted area, is a marker actually for other forms of deprivation. But when we look at animal models, animals develop tau pathology, rodents develop tau pathology if they're in a polluted area. So it does look like there's a direct biological link, although people that are who are in heavily polluted areas probably don't want to be there and may have lack of choice in their life and we don't have a safe level but and I think that individuals there's relatively little that you can do but I mean I've looked at a map personally for pollution and Tottenham Court Road, which is where I work, is about the highest, most polluted area in London.

Or where I work when it's not COVID. And but even going at. Even going a few streets back really makes a difference to the pollution levels. So with yeah, so I think that personally we can do that, but mostly thinking about pollution is a governmental intervention. The other thing about pollution is because everyone did it in a different way, we couldn't do what we would regard as in any way a valid meta analysis.

So our figures are looking from Canada, and actually Canada is one of the least polluted areas in the world, so we're probably underestimating for most of the world the effect of pollution. 

Jessamy: For those of, the listeners, my three year old son has just come in, so you did amazingly well to carry on your answer there, because he's been killing ants downstairs, it seems.

Anyway, what I found really incredible about the commission is that it illustrates what a whole of society problem dementia is. From air pollution to education. And I just wondered whether you might be able to tell us a little bit more about That kind of early life education and the future dementia risk issue.

Gill: I think it's really interesting what happens in terms of education and dementia. Because people who have more education are less likely to develop dementia, but it's not that they are less likely to have the neuropathology. So if you look at post mortem, they're just as likely to have the neuropathology, but they're more resilient to the neuropathology.

And it has less effects. So basically, what you're doing with early life education is you're building up a much more resilient brain, which can cope with, so that's what we call cognitive reserve. And since the 2017 Commission, there's evidence that we looked at 13 as a cut point, but it's evidence that up to age 20, you continue to build this resilience.

We don't have figures as to how much difference, but that's continuing education in younger people who have a plastic brain seems really important. Then after you're age 20, when you're an adult, people who do more cognitively stimulating things are more protected. People who retire later are more protected than those who retire earlier.

And that's not just in terms of the people who retire earlier might be sicker, because if you look at the country retirement age, that makes a difference. It's a policy thing as well. It probably has less effect. When you're an adult as to how much as to the difference it makes and because your brain is probably less plastic, but it continues to have an effect.

So there's a really important message about continuing to be cognitively active. And I don't mean doing brain training apps. I mean doing lots of different things to develop your whole brain and keep your whole brain moving. And we'll also, we'll not only make your life more fun and probably protect you a bit from depression.

But also will make you less likely to develop dementia. 

Jessamy: Yeah, and I guess it is those kind of more rounded types of activities that are gonna help them. And I don't know what the evidence is behind just socializing as well and doing that in groups and out of groups. Yeah, 

Gill: That's another thing that there's been a great increase in the evidence and that socializing.

Socializing by itself seems to make you so roundabout, so age 40, 50, 60, which is the times that people have looked at, makes you less likely to develop dementia. So having social contact is really helpful, not necessarily doing particular things, but just socializing. And socializing is a really cognitively demanding thing.

You have to pay attention to other people, listen to them. often in a group take on board what other people are saying and respond to them and you don't know what they're going to say. Socializing is cognitively demanding and it's obviously an interaction between hearing and socializing.

So if you can't hear, you avoid seeing a lot of other people because you can't. socialize with them properly. So the evidence about socializing is much stronger than it was and it seems really important and it's interesting that cross culturally wherever you look has a similar effect size and a similar effect.

So wherever you are, try and see other people, if you can, and chat to them. 

Jessamy: Yeah, go and have a cup of tea, get out of it, get out of the house if you can because of COVID 19. Yeah. Or Zoom. Or maybe talk to people 

Gill: in your house if you can't get out. 

Jessamy: Exactly. And I guess with COVID 19, inequality is on everybody's mind.

Yeah. And I was just wondering whether you could tell us a little bit about how tackling inequality may improve dementia risk, and treatment ultimately. So you, how equality may, yeah. In like tackling inequality can. 

Gill: Yes. Yes. Absolutely. If you look, and as you said, when you, it's really extremely obvious when you look at the risk factors, how societal they are.

It really makes a difference how society is set up and if you Are living in an area where it's difficult to walk around and there aren't any shops Then you're likely to be obese. You're quite likely to be hypertensive. You're quite likely to develop Diabetes and you're quite likely to have low all of these things are risks.

And while there are things you can do, things you can make a difference to individually, it's much more difficult. Within COVID, while we've been in, while people have been in the house, a lot of people have put on weight because they're living in a different way. And the way that society is set up really makes a difference.

And that, I talked earlier about the decrease in dementia. And the interesting thing is that these decreases tend to be in people who have more education and more resources. And inequality in society the way that people don't have the opportunity to live a healthy life really makes a difference, not just in the life that they're living now, but whether they'll develop dementia in the future.

Jessamy: It's fascinating. Terrifying in some ways that there's so much to do. So much to do, 

Gill: but really wonderful that, as people in Western nations have had, have smoked less and as they have had more education and their blood pressure has been more controlled, you can see that dementia has dropped and Interestingly, it's just, it's really men that have smoked less, and there's much less effect in women than there is in men.

There are, it's wonderful to see a change, because I think when I started the work in dementia, it didn't occur to me that this would happen. And it would be wonderful if Lancet and the Commission is part in driving through future change that will make things better for individuals and their families and society.

I'm sure it will do. I'm sure 

Jessamy: it will do. That seems like a great place to end unless there's anything else that you would like to say or add or make sure that we cover. No, I think that's a pleasure talking to you. A good place to end. It was a real pleasure talking to you. Thank you so much for joining us.

Alright, and thank you. Bye now. Bye-bye bye. I think what's so interesting about the Dementia Commission is it's really just brought back into focus that there are modifiable risk factors. So many of us think that dementia is just an inevitability, almost, of old age, and that there's nothing that you can do about it.

And I was reading, actually, that Cicero, 2, 000 years ago, was the first one to suggest that actually you can prevent cognitive decline by keeping, an active mind and doing things. And I think that's what is so great about the commission, is that, it just really highlights what you can do.

to reduce your risk. 

Gavin: Do you often go back to the works of Cicero for your research? 

Jessamy: I do! I go back to the works of Cicero on a daily basis, probably, Gavin. 

Gavin: I don't think that's true, is it?

But nevertheless, aside from Cicero, it is fascinating to think about how much Dementia and, in that sense long term suffering can be avoided through these modifiable risk factors. And how, of course, that this is going to become more and more of an issue as life expectancy increases, as general populations age, as the birth rate decreases and we have to support more and more older people as a society.

This is going to it's only going to become more and more of a problem. 

Jessamy: Yeah, and I think what sort of particularly struck me is just the burden that is on lower and middle income countries and how that's rising much faster than high income countries because of the increases in life expectancy.

And just the fact that it's something where we're really, we just seem very unprepared for that huge potential increase in these, growing countries. 

Gavin: Yes, it's one of those things really, isn't it, where we're only really still at the prevention stage, the treatments for it is underdeveloped that that it's really just a kind of case of coping with the burden and these are some ideas that could actually help reduce the the impact of dementia on society.

I was particularly interested you and Jill talked at length, I think, about About air pollution and air quality and ventilation and that sort of thing. And that's become a theme a lot recently talking about COVID 19, of course, as we always talk about. But also thinking about the state of cities and air quality there and how we might want to change things following the pandemic.

And of course As we were talking about in a recent episode to do with public transport, how we're going to have to alter things there to do with ventilation and air pollution. It's just really fascinating to think how actually not only does air pollution and ventilation tie into current health in terms of lung damage and infectious diseases, but also It has these really deleterious long term effects as well.

Jessamy: Yeah, there's a growing body of evidence that air pollution has, many effects on all of our bodies. And that is intuitive for us, of course, we think that should be right. But actually getting the empirical data is slightly trickier. So it's nice in a way To have this down as a risk factor for dementia.

You know that conversation that we had It's not I'm not sure it's hugely helpful for patients because it's not like you can say you know I live just outside London. Is that gonna reduce my risk of dementia or not? Maybe I live next to the m40 or whatever, but at least it's cut At least we're alive to the subject now 

Gavin: Yeah, absolutely.

And I think it's something that's becoming more and more prominent. And in fact, I remember just after I started at the Lancet, I was in a meeting with our deputy editor, and we were talking about air pollution, and she said, As anyone who's conducted lots and lots of autopsies knows, and at that point obviously my attention was piqued she said, anyone who's lived in a city, if you cut them open, their lungs will be black.

And that really, that's struck with me. That's stayed with me ever since, it was so striking. Is that 

Jessamy: surprising that such a vivid image would stick with you, Gavin? 

Gavin: Yes. Was that 

Jessamy: your introduction to the Lancet? Yes. Just discussion about chopping bodies open.

Yeah, I think that was the first three months. Now when you're cycling around, you've just got it there. 

Gavin: I'd just come to the Lancet from working at a food magazine, and the meetings are quite different.

Back to dementia, briefly. It's interesting as well, we're talking about pollution, but pollution and so many other of these modifiable aspects are burdens that fall on people who, sorry, I'll start that again. Feel like I've got some water here.

There we go, I shouldn't cough in the office, I'll be thrown out.

So talking about pollution and these other modifiable risk factors, there's so often things that have a greater burden of them falls on people who already suffer from the effects of inequality. Air pollution lifestyle risk factors like obesity, hypertension, those sort of things.

These things already have an impact on those on the worst off members of society. So it's just another one of those things. And it seems like we come back to it in every single discussion and in almost every single paper we publish that talks about, public health and global health that the worst effects of these things fall in an unequal burden on the worst off of society and around the world.

Jessamy: Yeah. And I suppose, this is a call to action in many ways for those things that are straightforward, like education. Like smoking, like obesity, they're simple public health interventions that we do know how to do. The majority of the gains in life expectancy of the sort of latter part of the 20th century were made because we were managed to reduce smoking.

We managed to reduce cardiovascular problems. So we do know how to do these. And it's just a case of making sure that it happens for everybody, rather than just, the top 10 percent of the wealthiest people around who, are able to keep fit and have hearing aids and get well educated and do exercise.

Gavin: The COVID 19 pandemic isn't just about infectious disease. During the first major pandemic in a century, we're really only just beginning to understand the manifold effects of a pandemic on already existing problems around the world. One of those is malnutrition. 

Jessamy: And I think we just wanted to clarify what malnutrition refers to, and that's deficiencies, excesses, or imbalance in a person's intake of energy and or nutrients.

And it covers quite a broad range of issues, including micronutrient malnutrition and overweight and obesity. But here you'll hear a lot of the word wasting and that comes under the undernutrition sort of factors for malnutrition. And that's essentially low weight for height. There's also things like stunting and underweight, but here it's mainly focusing on wasting.

Gavin: Before COVID 47 million children under five who were moderately or severely wasted due to malnutrition. New research suggests that the effects on food supply of the pandemic will make these effects much, much worse. So I spoke with Dr. Saskia Osundup. Who's the executive director of the micronutrient forum about these latest estimates.

And we talked about how exacerbating food inequality and driving malnutrition. Dr. Saskia Osendorp, thank you so much for joining me today. It's a real pleasure to have you. 

Saskia: Sure, thank you. 

Gavin: So we're talking about your comment that was recently published in The Lancet on child malnutrition and COVID 19. I guess kick us off then by explaining what specifically is it about COVID 19 that affects child malnutrition?

Saskia: So the COVID 19 crisis actually combines three different shocks that are affecting child malnutrition. The first is that particularly due to the containment measures, we see disruptions in the delivery of essential nutrition services. To children and pregnant mothers, and this this has been reported now by UNICEF that on average in the first months of the COVID crisis, they saw a reduction in coverage of essential nutrition and health services of about 30%, which could go down to 75 to 100 percent in some context during the real lockdown phases, and we know from previous crises that it may take about a year Before that, we'll go back to normal levels.

So that means that children are derived from essential services, such as vitamin A supplementation breastfeeding promotion. And mothers during pregnancy are derived from essential maternal nutrition interventions and micronutrient supplements. And in combination with that, we see a food systems crisis, food prices have soared, and the availability, particularly of nutritious foods, is affected particularly in urban areas.

Making it more and more difficult for children and their families to have access to healthy diets. And on top of that, there's a socioeconomic crisis and we have used for our projections, the projections for, of the World Bank in April that for individual countries, but that on an average.

Projected a 7. 9 percent decrease in incomes in 2020. We've brought together a group of scientists from the nutrition fields, the health fields, and the food systems fields, because we knew that this was not, this was such a complex crisis, to project what would be the combined 14%

Sorry, in a 14 percent increase in child wasting, so that would result in an additional 6. 7 million children who would become wasted in 2020 alone. And we know that severe wasting is the, is one of the most important causes of death among children in in low and middle income countries. So combined with the decreases in coverage that we see in essential nutrition and health services.

This would result in an additional 129, 000 child deaths before the end of the year. And that's an increase of 10, 000 deaths per month. So that's a very significant effect and that's just the top of the iceberg because we know when this crisis will last for longer. And the full impacts on social protection programs on food systems and health systems will will come out that we will see other forms of malnutrition being affected as well, including stunting, chronic malnutrition, and micronutrient malnutrition.

Gavin: Before COVID 19 hit, if you can remember back that far, where were we in making progress on tackling child malnutrition worldwide? And how much has this set us back? 

Saskia: Yeah, so before COVID 19, we were actually doing reasonably well in child malnutrition. We saw improvements in the percentage of children that were Stunted in particular some smaller improvements in children that are waste, that were wasted, which is acute malnutrition, and in some of the maternal nutrition and birth outcomes indicators, although of course we were not on track yet to meet the goals that the world has set itself in in 2030 to reduce all forms of to eliminate all forms of malnutrition.

So basically what we see happening now with COVID, so before COVID, we saw there was a projected 47 million children to be wasted in 2020. We now see that COVID might result in an additional 6. 7 million children wasted. And that will potentially could mean that by 2020, we will be at levels that we have not seen in the last 20 years, that basically means that the progress we've made in the last most much of the progress we've made in the last two decades could be lost by the end of this year.

And I think that's also the reason why, everyone is now so worried and is behind this call to action. Yeah, we really need to to have urgent actions to prevent this from happening. 

Gavin: It's very serious obviously, the the, as you said, the rolling back the last two decades of progress on, on child malnutrition.

What, what's being done as a result of child malnutrition caused by the COVID 19 pandemic? And what do you think needs to be done in kind of the near future to help? gain back some of this progress. 

Saskia: Yeah so the in the call to action that was published last week by the four UN directors they urged the international community to invest in nutrition now and to and they highlighted five priority actions that are That really need to be implemented straight away in order to prevent this from happening in 2020.

And these five actions include this to safeguard and promote the access to nutritious and healthy diets. And that could be done, for instance, by taking measures such as food vouchers for poor families or price policies to reduce the costs of a healthy diet. But also Making sure that trade barriers are selective and still allow the the import of nutritious foods to markets or the import of premixes that are needed to fortify foods when diets are not are not sufficient.

It also includes to invest in essential nutrition services through health systems by making sure that these services can be delivered in a safe way by protecting health workers, providing sufficient equipment for health workers during the crisis, as well as for food systems workers, by the way.

And these include services such as vitamin A supplementation, the promotion of breastfeeding and infant feeding. It includes the treatment of wasting children that are that, and the prevention of wasting. And it also means that the country should invest in the continuation of school feeding.

We know that many children are dependent on school feeding programs. And of course, with schools closing down because of the pandemic, these. programs are severely disrupted. There's a call to, to look for other means of ensuring that that children have access to these additional meals. And it includes the expansion of social protection programs, such as they can include the access to healthy diets as well.

Yeah. So I think that's what is needed now. And then when the crisis continue we, we really need to invest. in improvements in these essential nutrition programs, as well as improvements in making sure our food systems are able to resist similar shocks in future. And the This crisis will not result in a further inequity in the access to healthy foods and healthy diets that we have, that we have seen before.

We also know that the other forms of malnutrition that will also be affected as well as the fact that, we now have pregnant mothers being affected, which results in children being born. We know that. Children that are malnourished early in life will have difficulties later in school, so it will affect their learning capacities, it will affect their risks of chronic diseases and obesity later in life, as well as their ability to have a productive adult life and eventually it can even affect a country's GDP.

So it's really it's really social capital that's at stake here for the future generations as well. 

Gavin: Okay, so obviously COVID 19 will, will be over eventually and hopefully some of the things we can put in place can get us back on track with child malnutrition, it might take a while, but hopefully we'll get there eventually.

But what are some of the things we could do to guard against future pandemics, to guard against this kind of thing happening again? 

Saskia: When it comes to future, pandemics from a child malnutrition perspective, we really need to make sure that our food systems are more resilient to these kind of shocks, as well as the delivery of healthcare services.

Obviously, we've never seen this happening before that. Countries went into entire lockdowns and also the which also meant that these services were disrupted to the extent that we've seen during the COVID pandemic. I don't think we are arguing against lockdowns and social security measures because they were, they really needed to prevent the further spread of the pandemic, but we have to make sure That the delivery of essential services is being protected for in future pandemics.

We also have to make sure that our food systems rely on maybe shorter supply chains and rely on more domestic productions as well. And that there are social protection systems in place that can help when, when food systems collapse during future pandemics, that can help them for the low income families, especially to continue to have access to to nutritious foods.

Gavin: Okay. There's a lot to, there's a lot to take in there. It's incredibly important work and Thank you so much for talking about it with me today. 

Saskia: Thank you. 

Gavin: So it's fascinating to talk to Saskia there, and obviously it's such a depressing thing to think about, losing two decades of progress on malnutrition and wasting in one fell swoop due to the pandemic.

And it really, again, as we just talked about, it really highlights how COVID 19 is disproportionately affecting those who are worst off around the world. We in the current issue of The Lancet, our lead editorial discusses this, where we talk about more broadly, malnutrition falls under it, but more broadly, humanitarian crises around the world as well as malnutrition.

Talking about displaced populations, refugees people at risk from climate change, things like that. Even before this year started, as we mentioned in the editorial UN OCHA predicted that one in 45 people on the planet would need humanitarian assistance this year. And that's before you, you consider the effects of the pandemic on.

on people in low income settings. It's very depressing to think about, it's really, it's truly horrible. There's there's a lot of work that needs doing, but governments currently are dealing with their problems internally before looking outwards, so it's it's a bleak picture, basically.

The figures 

Jessamy: are shocking, only 6. 7 children, 6. 7 million children wasted. Which is going to result in an additional 10, 000 child deaths per month in the first 12 months. And 80 percent of those are going to happen in low and middle income countries. In India alone, 150 million children are now at risk of malnutrition due to the disruption of the world's largest lunch program.

But it's not even just lower in middle income countries. In the US, one in five children live in poverty and 30 million of those children. receive the childhood school nutrition programs, which have obviously been hugely disrupted over COVID 19. So it's one of those fundamental issues where the knock on effects are so large because undernutrition for children particularly makes them, at a much increased risk of infection.

So even before COVID 19, one in 10 child deaths under the age of five in lower and middle income countries were due to wasting. Having poor nutrition, the long term consequences, as you discussed during that interview, are just are so long and so multifaceted. 

Gavin: Yes, it's really, malnutrition in childhood causes so many knock on effects throughout life in an individual and across societies that those individuals are present in.

That it just, it really makes me think that. This is the first pandemic in a century, and we're really only just beginning to understand the effects of the pandemic and things that have been caused by the pandemic, such as lockdowns and emergency public health measures. We're only really beginning to just about understand the effects these are having.

On people's health that have nothing to do with COVID 19, all these programs being disrupted around the world people's livelihoods being affected, distribution of food and medicines being affected. It's such a vast and difficult to take in subject area that it really feels like you could do a PhD thesis on a tiny area of it.

And understanding the. incredible complexities of these systems feels overwhelming. 

Jessamy: I think there are some, also some really interesting things that it's highlighted about our lack of evidence and how, there are lots of issues in the world that have deteriorated and inequalities have been increased over the last 20 to 30 years and systems that are in place have not had the sort of proper funding or proper research into how they're.

How they're working and what the consequences are for individual countries, that we are in no man's land in a lot of areas. And things like food security, things like our food systems, there just hasn't been the kind of focus necessary to really understand, which countries are requiring, how many country I was looking at the data before in terms of, which countries require imported food and that sort of thing.

And, a lot of the data on the World Bank, they've collected it, and that's great. But some of it is very old. Some countries don't have anything from 2015 since before 2015. So You know, just having a good grasp on how countries are importing food and what proportion of their total national intake Requires, food from other areas and how those systems are in place.

We just haven't been focusing on that We don't have the research. We don't have the evidence for those things and this is just one example of many things which have gone under the radar really and nobody's focused on and now they are so crucially important because They have the, possibility of making many millions of people's lives in, a really terrible state.

Gavin: I think in a way you almost have to hope that this is the dress rehearsal of a pandemic. Do you know what I mean? We've talked so much over the last few months about how there are more pandemics to come, how this will absolutely not be the last one. You have to hope that we, as a planet, speaking grandly, will learn from all of these mistakes.

We'll learn where the gaps are, we'll learn where the research is that we needed, the data that we needed, the evidence that we needed, and we'll learn how to better supply and cope for the worst off around the world for the next one. But it's it's a lot to take on, isn't it? 

Jessamy: It is, and at the moment, with a complete lack of any global leadership, we still haven't had a global meeting of countries to sit down in some kind of emergency forum, like either the UN or anything else, to discuss these issues.

We haven't had that. It's it really beggars belief that we haven't had that kind of global leadership, that kind of global collaboration. Without that, it falls on WHO, but WHO is being defunded, people aren't listening to it. So it, it is a scary place to be. Yes. We hope that the world will learn from this and try and, implement some ways of.

of rectifying the problems that the sort of COVID 19 has shone a light on. But without any global leadership, it's not looking good. 

Gavin: No, I think the lack of global cooperation has been glaring. There's a great statistic to illustrate it, which is that the UN estimates that it's COVID 19 humanitarian response plan would cost the world 10.

3 billion. It's only been 20 percent funded by countries around the world. But. The total that countries have now spent on stimulus for their economies during this pandemic is 10 trillion dollars. A thousand times what would be needed to fund this plan, which is still only 20 percent funded. Hopefully, one of the lessons that the world will take from this is that The need for greater global cooperation is overwhelming and it's something that the world has absolutely flunked this time.

Jessamy: Yeah, and the fact that this sort of knee jerk response that we've had to so many things, of course we need recovery programs at a national level, if governments had the headspace and the leadership to be able to take a step back and think about the most effective and efficient ways to do those, Within a sort of more global context, then, we might not be spending money in the ways that we are, which may not be having the most effect.

Gavin: Thanks for listening to this episode of the Lancet voice. We'd love to hear your feedback and you can reach us through the email address podcast at lancet. com. We'll see you again 

next time.