Like HIV/AIDS, acute childhood malnutrition is deadly but easily treatable when the right approach is taken. Building on the success of PEPFAR, the Biden-Harris Administration should launch a global cross-agency effort to better fund, coordinate, research, and implement malnutrition prevention and treatment programs to save millions of children’s lives annually and eventually eliminate severe acute malnutrition.
Children with untreated severe acute malnutrition are 9 to 11 times more likely to die than their peers and suffer from permanent setbacks to their neurodevelopment, immune system, and future earnings potential if they survive. Effective programs can treat children for around $60 per child with greater than 90 percent recovery rates. However, globally, only about 25–30 percent of children with moderate and severe acute malnutrition have access to treatment. Every year, 3.1 million children die due to malnutrition-related causes, and 45% of all deaths of children under five are related to malnutrition, making it the leading cause of under-five deaths.
In 2003, a similar predicament existed: the HIV/AIDS epidemic was causing millions of deaths in sub-Saharan Africa and around the world, despite the existence of highly effective treatment and prevention methods. In response, the Bush Administration created the President’s Emergency Plan for AIDS Relief (PEPFAR). PEPFAR has proven a major global health success, saving an estimated 30 million lives since 2003 through over $100 billion in funding.
The Biden-Harris Administration should establish a President’s Emergency Plan for Acute Childhood Malnutrition (PEPFAM) in the Office of Global Food Security at the State Department to clearly elevate the problem of acute childhood malnutrition, leverage new and existing food security and health programs to serve U.S. national security and humanitarian interests, and save the lives of up to 3.1 million children around the world, every year. PEPFAM could serve as a catalytic initiative to harmonize the fight against malnutrition and direct currently fragmented resources toward greater impact.
Challenge and Opportunity
United Nations Sustainable Development Goal (SDG) 2.2 outlines goals for reducing acute malnutrition, ambitiously targeting global rates of 5 percent by 2025 and 3 percent (a “virtual elimination”) by 2030. Due to climate change, the COVID-19 pandemic, and conflicts like the war in Ukraine, global rates of malnutrition remain at 8 percent and are forecast to become worse, not better. Globally, 45.4 million children suffer from acute malnutrition, 13.6 million of whom are severely acutely malnourished (SAM). If current trends persist until 2030, an estimated 109 million children will suffer from permanent cognitive or physiological stunting, despite the existence of highly effective and relatively cheap treatment.
Providing life-saving treatment around the world serves a core American value of humanitarianism and helps meet commitments to the SDGs. The United States Agency for International Development (USAID) recently announced a commitment to purchase ready-to-use therapeutic food (RUTF), a life-saving food, on the sidelines of the UN General Assembly, demonstrating a prioritization of global food security. Food security is also a priority for the Biden Administration’s approach to national security. The newly released National Security Strategy dedicates an entire section to food insecurity, highlighting the urgency of the problem and calling on the United States and its global partners to work to address acute needs and tackle the extraordinary humanitarian burden posed by malnutrition. The Office of Global Food Security at the U.S. Department of State also prioritizes food security as an issue of national security, leading and coordinating diplomatic engagement in bilateral, multilateral, and regional contexts. At a time when the United States is competing for its vision of a free, open, and prosperous world, addressing childhood malnutrition could serve as a catalyst to achieve the vision articulated in the National Security Strategy and at the State Department.
“People all over the world are struggling to cope with the effects of shared challenges that cross borders—whether it is climate change, food insecurity, communicable diseases, terrorism, energy shortages, or inflation. These shared challenges are not marginal issues that are secondary to geopolitics. They are at the very core of national and international security and must be treated as such.”U.S. 2022 National Security Strategy
Tested, scalable, and low-cost solutions exist to treat children with acute malnutrition, yet the platform and urgency to deliver interventions at scale does not. Solutions such as community management of acute malnutrition (CMAM), the gold standard approach to malnutrition treatment, and other intentional strategies like biofortification could dramatically lower the burden of global childhood malnutrition. Despite the 3.1 million preventable deaths that occur annually related to childhood malnutrition and the clear threat that food insecurity poses to U.S. national security, we lack an urgent platform to bring these low-cost solutions to bear.
While U.S. government assistance to combat food insecurity and malnutrition is a priority, funding and coordination are not centralized. The U.S. has committed over $10 billion to address global food insecurity, allocating dollars to USAID, Feed the Future, the U.S. Department of Agriculture (USDA), and others. Through the recently signed Global Malnutrition Prevention and Treatment Act of 2021, Congress took a step forward by authorizing USAID to have greater authority in targeting nutrition aid to areas of greatest need and greater flexibility to coordinate activities across the agency and its partners. In accordance with the agency’s Global Nutrition Coordination Plan, Congress also established the Nutrition Leadership Council, chaired by the Bureau for Resilience and Food Security to coordinate and integrate activities solely within USAID. Multilateral and private sector partners also dedicate resources to food security: the Gates Foundation committed $922 million toward global nutrition and food systems, and UNICEF created a Nutrition Match Fund to incentivize funding to combat severe acute malnutrition. These lines of effort are each individually important, but could be more impactful if aligned. A President’s Emergency Plan for malnutrition could harmonize these separate funding streams and authorities and mobilize multilateral and private sector partners to prevent and treat malnutrition and food insecurity.
Drawing on the strengths of the PEPFAR model to combat HIV/AIDS at scale while driving down costs for treatment, PEPFAM could revolutionize how resources are spent while scaling sustainable and cost-effective solutions to childhood malnutrition, saving millions of lives every year. Under this model, significantly more—and, optimally, all—children suffering from acute malnutrition would have access to treatment. This would make dramatic progress toward global food security and U.S. national security priorities.
Plan of Action
President Biden should declare a global childhood malnutrition emergency and announce the creation of the President’s Emergency Plan for Acute Childhood Malnutrition. Using PEPFAR as a model, PEPFAM could catalyze cost-effective solutions to save millions of lives every year. When President Bush mobilized support for PEPFAR in his 2003 State of the Union, he declared, “We must remember our calling, as a blessed country, is to make the world better,” and called for interagency support for an “Emergency Plan” for HIV/AIDS relief and Congressional support to commit $15 billion over the next five years to launch PEPFAR.
President Biden should follow a similar path and announce PEPFAM in a similarly high-profile speech—the 2023 State of the Union address, for example—to elevate the problem of acute childhood malnutrition to the American people and the U.S. government and offer a clear call to action through an executive order directing an interagency task force to develop a 24-month strategic plan within 180 days. The initial stages of PEPFAM and corresponding executive branch activities can be guided by the following recommendations.
Recommendation 1. Name a White House PEPFAM czar and task the Office of Global Food Security at the State Department to coordinate cross-agency support, intended personnel, agencies, and roles involved.
A Senior Advisor on the White House’s National Security Team at the Office of Science and Technology Policy would serve as the White House czar for PEPFAM and would (1) steer and lead the initiative, (2) organize an interagency task force, and (3) coordinate PEPFAM’s strategic focus by engaging multiple federal agencies, including:
- USAID’s Bureau of Resilience and Food Security
- State Department’s Office of Global Food Security
- State Department’s Office of the Global AIDS Coordinator and Health Diplomacy (OGAC)
- Department of Health and Human Service’s Office of Global Affairs
- Department of Agriculture’s Foreign Agricultural Service
- The White House National Security Council (and/or other relevant offices)
The Office of the Global AIDS Coordinator and Health Diplomacy at the State Department (OGAC) manages the high-level execution of PEPFAR by dictating strategic direction and coordinating agencies. The PEPFAM executive order will set up a similar infrastructure at the Office of Global Food Security at the State Department to:
- Coordinate activities and funding across the U.S. government, the private sector, and multilateral organizations
- Approve all activities related to PEPFAM
- Oversee accountability and monitoring and evaluation
- Provide strategic direction for the program
USAID is also well positioned to play a leading role given its current support of global food and nutrition programming. Several of USAID’s portfolios are central to PEPFAM’s aims, including Agriculture and Food Security, Nutrition, Global Health, Water and Sanitation, and Humanitarian Assistance. The offices that support these portfolios should provide technical expertise in the realm of food and nutrition, existing connections to good program implementers in various country contexts, monitoring and evaluation capacity to track implementer’s progress toward goals, and strategic direction.
The Office of Global Food Security and the PEPFAM czar should delegate authority for the program across government agencies, private partners (e.g., Gates Foundation), and multilateral organizations (e.g., World Food Programme). The Office would coordinate interagency action to support PEPFAM’s implementation and evaluation as well as identify agencies that are best placed to lead each component of the effort.
Recommendation 2. Present initial, strategic action plan to build and sustain PEPFAM.
The PEPFAM interagency task force, described above, should develop a strategic plan targeting an initial set of actions to align with existing global food security and childhood malnutrition priorities and identify opportunities to redirect existing resources toward scalable, high-impact solutions like CMAM. USAID already invests millions of dollars each year in initiatives like Feed the Future that support global food security while overseeing cross-agency implementation and harmonization of the Global Food Security Strategy. These efforts and funding should be rolled under the umbrella of PEPFAM to better align treatment and prevention interventions, strategically coordinate resources across the government, and improve a focus on impact.
Recommendation 3. Announce discrete, evidence-driven goals for PEPFAM.
These goals include:
- Catalyze global funding and direct resources toward effective, low-cost solutions to address acute childhood malnutrition.
- Provide sustained access to treatment for children suffering from acute malnutrition, both moderate and severe, even in geographic areas that are not designated as crises or emergency situations.
- Scale proven, cost-effective prevention interventions to reduce the burden of childhood malnutrition and invest in research and evaluation to identify new prevention mechanisms.
- Coordinate and conduct targeted humanitarian efforts to triage and respond rapidly to emergent situations of famine/starvation.
- Invest in research, innovation, and monitoring and evaluation to ensure that U.S. government and global funds are put toward the most cost-effective (e.g., cheap and effective) interventions to maximize the impact of existing and additional funds.
Recommendation 4. Establish a coordination framework between PEPFAM, multilateral agencies, and private sector partners to mobilize and harmonize resources.
The Office of Global Food Security and USAID should build on current momentum to bring multilateral and private partners behind PEPFAM. USAID has recently announced a series of partnerships with large philanthropic organizations like the Gates Foundation, Aliko Dangote Foundation, and Eleanor Crook Foundation (to name a few), as well as other countries and multilateral organizations at UNGA. Much like with PEPFAR, PEPFAM could rely on the support of external partners as well as federal funds to maximize the impact of the program.
Recommendation 5. Create an international council to set technical standards so that money goes to the most effective programs possible.
The Office of Global Food Security, USAID, and PEPFAM should spearhead the development of an international technical council (that could be housed under the UN, the World Health Organization, or independently) to set standards for malnutrition prevention and treatment programming. Malnutrition treatment is already cost-effective, but it could be made even cheaper and more effective through innovation. Even when promising new interventions are identified, the process of disseminating and scaling of existing, proven best practices innovations doesn’t function optimally.
Treatment guidelines issued by the WHO and national governments are slow to be updated, meaning that highly effective interventions can take years to be adopted and, even then, are adopted in a piecemeal fashion. Other implementers may be too wedded to their operational practices to consider making a change unless standards are updated or innovations from other implementers are actively socialized.
An international technical council would disseminate and scale best practices discovered in the processes of implementation and research. If funders like the U.S. government commit to only funding organizations that promptly adopt these standards, they can maximize the impact of existing funding by ensuring that every dollar goes toward the most cost-effective ways of saving lives. This body could ideally speed the sharing and implementation of practices that could allow more children to be treated effectively, at lower costs.
Recommendation 6. Direct existing child malnutrition assistance through PEPFAM to ensure coordinated impact and seek permanent funding from Congress for PEPFAM.
The executive order will create the momentum to establish PEPFAM, but legislative authorization is required to make it sustainable. The strategic plan should lay out efforts to build Congressional support for funding legislation.
Congress will play a key role in PEPFAM implementation by appropriating funds. Under PEPFAR, Congress appropriates money directly to OGAC at the Department of State, which disburses it to other agencies. In 2003, Congress supported President Bush’s request for $15 billion in PEPFAR funding by passing the Leadership Act that authorized yearly contributions to the Global Fund from 2004 to 2008. Congress has subsequently reauthorized the program through FY2023. Each year, the OGAC presents a request of funding needed for recipient countries and programs to the President, who then forwards the request to Congress for reauthorization. The PEPFAM process should mirror this structure.
At the UNGA in 2022, President Biden announced over $2.9 billion in new assistance to address global food insecurity, building on the $6.9 billion in U.S. government assistance already committed in 2021. Last year, President Biden also announced a $10 billion, multiyear investment to promote food systems transformation, including a $5 billion commitment to Feed the Future specifically. Instead of fractured funding to different initiatives, these funds should be harmonized under PEPFAM, with dollars allocated to the PEPFAM task force to create a centralized two-year strategy to combat malnutrition.
This program would have a series of positive effects. First, and most obviously, PEPFAM would save up to 3.1 million lives every year and bring together resources and goals around food security that are currently fractured across the federal government, increasing the effectiveness of U.S. aid dollars globally. Second, PEPFAM, like PEPFAR, would make existing interventions more effective by unlocking cost savings and innovation at scale. Third, at a time when the United States is competing for its vision of a free, open, and prosperous world, PEPFAM could play a key role in achieving the mission of the National Security Strategy.
Over time, more comprehensive treatment coverage and prevention efforts could also lead to the elimination of severe acute malnutrition by preventing cases and catching those that approach moderate acute malnutrition or have already fallen into it. PEPFAM would save an estimated 27.9 million lives over the same time scale as PEPFAR. Millions of children die every year while a cheap and effective solution exists. PEPFAM could change that.
Frequently Asked Questions
From 2003 to present day, PEPFAR has spent billions of dollars and saved millions of lives. This table compares the estimated costs and outcomes of PEPFAR with PEPFAM. Because malnutrition treatment is cheaper than HIV/AIDS treatment and there is a higher caseload, there is a high-leverage opportunity to save lives.
|PEPFAR (HIV/AIDS)||PEPFAM (Childhood Malnutrition)|
|Average Cost of Treatment per Person||$367,134||$60|
|Number of Cases||38.4 million||45.4 million|
|Program Cost (estimated yearly)||$5.7 billion (USD)||$4 billion (USD)|
|Lives Saved (estimated yearly)||1.6 million||1.5 million|
Costs for PEPFAM are difficult to project precisely, because the program is likely to become more cost-effective over time as efforts to prevent cases start to work and research and development result in cheaper and more effective treatment. The projections above operate under the most pessimistic assumptions that no improvements to cost or effectiveness are made over time. This graph illustrates a similar the expansion of PEPFAR services, even under flat budgets thanks to this same self-improvement over time.
PEPFAM is similar: more comprehensive treatment coverage and prevention efforts could lead to the elimination of severe acute malnutrition by preventing cases and catching those that approach moderate acute malnutrition or have already fallen into it. That means that the program should become cheaper over time, as more cases are identified earlier when they are cheaper to treat, and more cases are prevented, both by prevention programs and general economic development. Research and innovation can similarly cut down on the costs and improve the effectiveness of malnutrition treatment and prevention over time.
The lack of attention to childhood malnutrition in non-emergency/non-crisis zones results in millions of preventable deaths each year. Declaring an emergency would put pressure on other organizations, media outlets, and NGOs to devote more resources to food security. The international community is keen to respond to food crises in emergency contexts, especially among children. USAID and the UN recently committed millions of dollars for the procurement of ready-to-use therapeutic food (RUTF) to combat emergency risks like the war in Ukraine and conflicts in places like Ethiopia. But the unfortunate truth is that even outside of newsworthy emergencies, acute malnutrition remains a daily emergency in many places around the world. Malnutrition rates are just as high in states and countries that neighbor emergency zones as in the crisis-hit places themselves, partially as a result of movement of internally displaced people. While funding acute malnutrition in relatively mundane circumstances (e.g., poverty-stricken states in Nigeria) may make less headlines than emergency food aid, it’s equally needed.
Currently, only 1 percent of U.S. global health spending is put toward nutrition. Only 25–30 percent of children globally have access to treatment as a result of underfunded programs and a subsequent lack of resources and geographic coverage.
Treatment is only effective if implemented well. Right now, funding goes to a range of programs that fail to meet Sphere Standards of 75 percent recovery rates. Large-scale funders like UNICEF have internal commitments to spend a certain amount of their budgets on ready-to-use therapeutic food (RUTF) a year, which means that their hands are tied when working in contexts with poor implementing partners (e.g., corrupt governments). At the same time, NGOs like Alliance for International Medical Action and Médecins Sans Frontières achieve recovery rates of more than 95 percent. More investment in quality implementation capacity is needed; otherwise, scarce existing resources will continue to be wasted.
There’s a growing movement to implement interventions that catch children on the border of malnutrition or improve conditions that lead to malnutrition in the first place (e.g., infant and young child feeding circles, exclusive breastfeeding counseling). These programs are exciting, but the evidence base for impact at this point is minimal. It’s much cheaper to catch a child before they fall into malnutrition than it is to treat them, not to mention the health benefits to the child from averting the disease. More work needs to be done to test and validate the most cost-effective prevention methods to ensure that only those that actually generate impact are scaled.
Childhood malnutrition sits at the intersection of public health and nutrition/agricultural programming. Current efforts are spread across the U.S. government and multilateral partners with little coordination toward desired outcomes. Funding that hypothetically targets childhood malnutrition can come from a variety of players in the U.S. government, ranging from Department of Defense to USAID to the Department of Agriculture. While some coordination through programs like Feed the Future exist at USAID, these programs are not yet results- or outcome-based. Coordination should involve measuring the impact of collective aid across agencies on an outcome like recovery rates or the number of children suffering from malnutrition in a given geographic area.
PEPFAM’s success should be judged based on the outcomes as described below, rather than inputs or outputs. The amount of spending or the number of programs launched should not be taken as a substitute for the results outlined here. A commitment to outcomes would massively improve results. If even 1 percent less was spent in malnutrition treatment programs thanks to improved efficiency or innovation, an estimated $3.4 million in existing funding would be freed up, allowing an additional 50,000 children to be treated every year, in perpetuity.
- Decreased number of cases of malnutrition globally
- As a function of improved prevention efforts and expanded treatment.
- Increased recovery rates in U.S. government-funded malnutrition treatment programs
- As a function of improved implementation and research and innovation to improve efficacy.
- Decreased cost-per-child of malnutrition treatment efforts
- As a demonstration of improved practices and as a means of using existing resources to treat more children.
- Changes in on-admission anthropometrics in key countries
- On-admission anthropometrics (e.g., the weight, height, and mid-upper arm circumference of a child) are used to diagnose whether a child has malnutrition. Very low on-admission anthropometrics across a given geographic area indicate low treatment and prevention coverage because cases are caught late, when they are more severe. If treatment and prevention interventions work in a given area, these metrics should be higher on average upon admission.