Good morning, everybody. My name is Delia Grace. I'm a veterinary epidemiologist based at IRE, the International Livestock Research Institute in Nairobi, Kenya, where I lead a programme on animal and human health, and I also lead the flagship on food safety at the CGIR.
The CGIR is a network of 15 international research centres based in developing countries. I'm happy to be with you today and to share some recent information on food safety in the domestic markets of developing countries. This presentation is based on more than a decade's work on food safety in mainly Africa and Asia.
And we have produced several research outputs which summarise key findings. These include a paper for DFIT on the evidence on food safety in developing countries, and the first and so far only book on food safety and informal markets. All of these are freely available online.
Recent years and especially last year has seen a growing interest in food safety in in in informal markets, and there are several new initiatives in 2018. 1 was a white paper by USAID on food safety. Another was a publication by the World Bank on food safety in, in, in informal markets.
And then an important report led by ILRI and Chatham House, the UK think tank on the importance of food safety and animal source food in the 1st 1000 days. And all of this has drawn on early research and I'm happy to share some current findings. This presentation has 4 main themes.
The first is why it matters, looking at the impact of foodborne disease in developing countries. The second is on measuring food safety. We all know that what, what cannot be measured cannot be managed, and there are two key metrics for understanding food safety, what we call values and dollars.
So I'm going to talk a little bit about those and how they're calculated. The third part of the talk is a deeper dive into foodborne disease in developing countries. What causes it, what foods are implicated, and the trends.
And the 4th and most important part of the talk is about managing foodborne disease, what we know, what we don't know, and the ways forward. So to start with the impact of foodborne disease, I think the first message here is that as the saying goes, health is too important to be left to doctors or veterinarians. So foodborne disease matters because it has a set of wider implications for development and particularly for the attainment of the sustainable development goals.
The sustainable Development Goals being the new framework, which sets out how we do development. This is a follow on from the Millennium Development Goals, which targeted some rather narrow areas of health, well-being, and they have been expanded into a much broader range of goals to be attained by 2030. Health is among the first three, and so is poverty.
Foodborne disease matters to these sustainable development goals for reasons which go beyond health. One of the reasons is that consumers show a high concern over foodborne disease. I think many of you may be aware of the scandals in China over melamine, where milk was contaminated with a chemical which resulted in children dying, and this led to enormous political change and indeed a, a, a reconstruction of the way foodborne disease was managed.
This is not surprising. We've seen similar things even in the UK where the BSE crisis was instrumental again in, in creating huge public concern and leading to far-reaching changes in the way food safety was managed. So the high concern of consumers over food safety makes food safety a very political issue.
The next issue, of course, is the huge health burden, and I'll be presenting some recent information on this later in the presentation, because this is a relatively new understanding. I've been working in disease in, in livestock-related human disease for several decades, and I would say for most of those decades, food-borne disease was not really considered a big issue. Probably much more attention was being paid to either the emerging diseases, avian influenza, MERS, SARS, or else the, the classical zoonosis, things like tuberculosis, cystic sarcosis, brucellosis, many of which, of course, are foodborne also.
But foodborne disease as an entity, as, as a category of disease was not really regarded as a high priority. This all changed due to a landmark report of WHO which we'll talk a little bit about later. But beyond health, foodborne diseases high economic costs, both associated with health, but also associated with the agriculture, export, and the economy.
Foodborne disease also limits the access of poor farmers to get to highly remunerative markets. We've seen in the past couple of decades, a, a, a, a change of feeling in the development community that just aid by itself, aid and handouts is not going to close the gap between poor countries and rich countries. So there's been a lot of interest in things what what has been called trade not aid, in sort of allowing and supporting developing countries to, to Pull themselves out of poverty through their own resources and expertise.
And of course, there has been most dramatic success in Southeast Asia, where China has moved more than 90 million people out of poverty through market-based interventions. And finally, foodborne disease is also an equity issue. That is to say, we may say that foodborne disease discriminates.
We have a saying in the, in the foodborne disease community that a certain group are most at risk, what are called the yuppies, the young, the old, the pregnant, and the immunosuppressed. And most veterinarians will know that certain diseases, such as, for example, toxoplasmosis or Listeriosis associated with, with unpasteurized milk and soft cheeses are at a special risk for pregnant women. And obviously, infants with their not fully developed immune system and the elderly with their waning immune system are also at higher risk.
In developing countries, we add another category, that is the malnourished. Who are at higher risk than others of foodborne disease, bringing us up with the yon piece rather than the Yorkies. Around 2 billion people in developing countries are malnourished, either lacking micronutrients, proteins, fats, carbohydrates, or as micronutrients, the minerals and vitamins, which lead them to be more at risk from food-borne disease.
I'm going to talk a little bit more about these categories because they really show why foodborne disease matters for development. Health, health comes first. As I said, foodborne disease was not regarded as a health priority in developing countries until 2015, when the World Health organisation released the first global estimate of the burden of foodborne disease.
This was over 10 years in the making, and involved over 60 experts, including some scientists from IRI. This this study found that the burden of foodborne disease was comparable to that of malaria, HIV AIDS, or tuberculosis, what we call the big three in health in developing countries. The study looked at 31 hazards and found that together they comprised over 600 million illnesses a year, 420,000 deaths, and a burden of 30, 0, 33 million dies.
We're going to come back to what that 33 million dies means. But I should just flag up that this study showing a huge burden was very conservative. We have good studies in America which suggest one in 6 people fall ill every year from foodborne disease.
Similar studies in Greece say it's 1 in 3 people, but this far global study said that in Africa, only 1 in 10 people fall ill from foodborne disease. And I think that most people would say that is an estimate on the conservative side. It's hard to think that food is so much safer and people are so much less vulnerable in Africa than in Greece.
So the huge health burden of foodborne disease. But there's also many implications for foodborne disease and livelihoods. This is a summary which we did at ILRI when we looked at gender and food safety in 26 different value chains, informal value chains.
And what we found was that women have a very important role in, in these value chains, and that women are actually key to ensuring food safety. And we also found that as markets formalise, women get forced out. And we see this in other areas of agriculture.
It's the woman with the hole in her hand, but the man driving a tractor. And in developing countries, although in, in richer countries, for example, in poultry, in poultry processing, women often dominate, in, in poor countries, these are innovations and the men dominate. Just to show you the, the, this graph, it summarises or this diagram summarises the role of men and women.
You can see that men are often involved in production or capture, that's in blue. But in some value chains, women dominate in production, especially in poultry, and women often dominate in processing are highly involved in marketing and consumption, of course, affects everyone. Another important areas food safety and nutrition.
There's been huge concern in recent years over the burden of malnutrition, both the visible burden in terms of, of people going hungry and the invisible burden and people having inadequate diets. A lot of this concern centres around stunting, which means children being too small for their height. Children who are stunted will through their lifetime have lower incomes, lower cognitive performance, worse outcomes than children who are not stunted.
And stunting, once you get beyond a certain age, is almost irreversible. So stunting, managing, ending stunting is really key to future development, human development in, in poor countries. And food safety has a large and sometimes underestimated role in nutrition.
It's a risk factor for stunting and is perhaps responsible for 10 to 20% of the total burden of stunting. But beyond that, unsafe food often contains large amounts of faecal material, which may contribute to a condition called environmental enteropathy or leaky gut. So this is where even in the absence of diarrhoea, kids have poor unhealthy gut performance, which means they can't absorb nutrients from their gut.
There's another association between aflatoxins, this fungal toxin I mentioned, which is highly prevalent in food in tropical countries and may be directly responsible for stunting. Beyond this and indirectly, there's a concern that regulations aimed to improve food safety may actually decrease the availability and accessibility of foods. This is a complex trade-off, and it's sometimes summarised in the phrase, the best is the enemy of the good.
That means that when regulations are made from a health perspective, experts may, for example, insist on pasteurisation. Pasteurisation of milk is a highly effective way of reducing hazards. But in Kenya, where I work, the cost of pasteurised milk is around double the cost of raw milk, which means that parents who are who are forced or who are persuaded to buy pasteurised milk are going to give a lot less milk to their children.
However, in Kenya, more than 99% of households boil milk, so in this case, pushing for pasteurisation may not be the most effective response. Food safety also decreases access to markets, and here we're going into paradoxical effects that though we all want safer food, we have to understand that pushing for food safety in contexts which are complicated may have unintended consequences. So studies have shown that where food safety standards ratchet up, we tend to see smaller, poorer female farmers getting excluded from these markets.
Markets similarly, in domestic markets, farmers supplying supermarkets are richer, better educated and more likely to be male. Another risk about good food safety standards, which we all want, is that you get segmented markets. So in very poor countries, substandard food is not destroyed.
It ends up being eaten by the poorest people. And we've seen that where, for example, stricter standards apply for milk, that what happens is people, women usually bring the milk to the cooperative. Some is accepted, some has refused.
The milk that is refused, they bring it home and give it to their children. So regulating for food safety is complex and needs to be done holistically. However, regulations on the whole are still not very important.
These quality demanding markets, the supermarkets and the export markets are a small share of overall markets. And the good news is that smallholders and women can participate in these markets if they get help, and they will have some benefits by learning, by, by having better capacity. So that was my first and longest section on why foodborne disease matters so much to developing countries.
Our next section is going to look at measuring food safeties and the two essential metrics of dollars and dollars. So first of all, why do we need to measure? Well, there's a saying in food safety that what you worry about and what makes you sick and kills you are not the same.
Risk misperceptions abound. And we often see this when we look at chemical and biological hazards. So when we ask laypeople, and when we ask policymakers, which is the most serious, chemical hazards or biological hazards, they nearly always say chemical hazards.
And yet when we do the studies, we find the reverse is the truth. For example, below, I'm just summarising some results from a study in Port Valli Chain of Vietnam. We looked at a large number of samples and examined them for various chemical hazards, antibiotic residues, growth promoters, heavy metals, and we actually found that the most of them were within the maximum recommended limits and those which were over had minor implications for human health.
On the other hand, we, we conducted a quantitative microbial risk assessment for salmonellosis. And here we found that among pork eaters, which are about 95% of people in Vietnam, they can, 13% can expect to fall ill every year from salmonellosis. And this was driven mainly by cross-contamination in households followed by prevalence in pork.
And again, we see what people were worrying about the chemicals and what was making them sick here, the salmonellosis were not the same. We also have looked at experts because often in countries where evidence is very weak, and I'm afraid that is most developing countries when it comes to food safety, people say, well, we don't really know what's going on, so let us ask some experts. But unfortunately, the experts also don't really know what's going on.
And here's a study from, we, we did from Ethiopia, where we compared what experts said were the food safety problems, and what the study, the WHO study said were the food safety problems. And you can see that the experts in green, they tend to think everything is a problem. And they tend to think that things which have got a kind of a scary reputation like anthrax and Brussella are a big problem.
Whereas when we actually look at the food-borne disease burden in dailies, we find that there are a few hazards which are a big problem and many things which are a less problem, and that there is not very much agreement between the real burden and the experts. So if the people, if public and decision makers aren't very good, and if experts aren't very good, how do we know what are the problems in, in foodborne disease? Well, fortunately, we have two useful metrics.
The first is a health outcome metric, and it's something called disability adjusted life years. What this does is it combines both morbidity and mortality, both sickness and death. And this also allows us to compare the burden of different diseases, both within foodborne disease if we want to compare anthrax and E.
Coli, but also we want to compare foodborne disease and, and malaria. This, of course, facilitates prioritisation, cost-effectiveness analysis, and monitoring. So basically, a disability adjusted life here has two components, the quantity of life lost, reduced due to a disability, and the quantity lost due to dying too young.
The way it can be measured, and here is just an example, is you have to work out how much is lost due to sickness and how much is lost due to death. So if we take the example of somebody who has a Campylobacter infection and then develops Guillain-Barre syndrome, she has a year, a week of diarrhoea, and a year of paralysis. We can assume that the year with paralysis is equivalent to a year with only 10% of being normal.
So a year with paralysis, you only live, you only have 10% of your satisfaction or utility you would if you didn't have paralysis. And, and with diarrhoea, you have 80% of your satisfaction. So then you, you work out the, the weight of the disability, the total loss, add them together, and that gives you your disability adjusted life year.
Of course, the other key metric is dollars. Working a lot in food safety with with health professionals, both medical and veterinary, they often say we go to the Ministry of Finance, they're interested in the health burden, but what they really care about is the dollar cost, and we won't get investments until we show the cost of foodborne disease. As the WHO did this landmark study in the health burden, the World Bank has also come out with an important study on the economic loss of foodborne disease, and we were partners in this.
That's just been released last month, and it's available on the internet. The key take home finding from this is that developing countries have a huge economic loss associated with foodborne disease, and most of this is what we call productivity loss, and that is the loss from people being ill, and because they're ill, they can't work. The productivity loss is around $95 billion a year in developing countries.
The cost of treatment, this is the cost of people having to, to pay out of pocket to be treated, is around $15 billion. And the cost from trade is around 5 billion. Up to now, nearly all the investments in food safety have been in trade, and almost none have been in the domestic public health costs of foodborne disease.
There's another report coming out next year by the GFSP, the Global Food Safety Partnership, which summarises evidence of 1010 years donor and Investment in food safety in Africa. And that very clearly tells this tale that for 10 years we've been investing in trade. It hasn't been lost money, I would say.
It's been a good use of money, but if you look at where the huge losses are, they're not associated with trade. They're associated with people becoming sick in domestic markets. So that takes us to part 3, where we do a deeper dive into foodborne disease in developing countries.
What causes this, what foods are implicated, and what the trends are. This takes us back to that, that study I mentioned the WHO study by called the FARC report, the Foodborne Disease Epidemiology Research Group. So this summarises the burden in low and middle-income countries in terms of ties.
We've talked about disability adjusted life years, and what is causing it. And I think you can easily see that microbes, viruses, and bacteria are responsible for a lot of the burden. Helminths, these are, are worms, things like Ascaras, cystic sarcosis, chinococcus, are also substantial, but that the burden by toxins is relatively small.
Going back to what we said about what people worry about and what makes them sick and kills them is not the same. I should add that there's another work ongoing looking at a set of toxins which are heavy metals, and that will probably be published in 2018, and the burden from these are around about $10 million. So if you can imagine that will be higher than the burden from Helmutts and we'll add considerably.
To the burden of foodborne disease. But if you look at the pie chart on the other side of the screen, you'll see another interesting result for veterinarians, that if we look at the hazards responsible for this burden, more than half of them are zoonotic diseases. And this obviously has implications on how we manage foodborne diseases and who should be responsible for managing them.
And we'll return to one health and the role of veterinary public health in the 4th and last section of this presentation. So unsurprisingly, when we see such a high burden associated with zoonosis, we might suspect that animal source food, meat, milk, eggs and fish, would have a role in foodborne disease. Well, this is what we call attribution data, which is the science of attributing health burden to foods.
And I would say that this is much weaker than actually understanding the burden, which is knowing what is the health burden in disability adjusted life years and the economic burden of foodborne disease. But still, there is some data, and there is some consistency in this data. This is a systematic review which I did, which we did, and as you can see in green across a number of countries, the animal source foods are quite important.
And the next most important is produce, which means fresh, fresh fruit and vegetables. And actually this is mainly fresh vegetables rather than fresh fruit. The produce too often involves animal source food because quite a lot of the problems with produce is due to Growing vegetables in soil contaminated by animal and human faeces which have not been composted, so there is an indirect link with with animal source food.
WHO found the somewhat similar results as regards to attribution, which are the foods, which are the risky foods we need to worry about. And here you can see that meat in red, fish in blue, milk in white are responsible for, for more than 3/4 of the, of the foodborne disease. So another worry, another aspect of foodborne disease, which is rather worrying is that foodborne disease appears to be getting worse, unlike most other infectious diseases.
Most of you have heard of the epidemiological transition, which is the, on the whole, good news that Infectious diseases are trending down, although unfortunately, non-communicable diseases, diseases like cardiovascular diabetes, are, are trending up. But the infectious diseases, which were such an important cause of death in the past, have been consistently descending. For example, between 2006 and 2016, tuberculosis has decreased by around 23%, HIV by 44%, malaria by 27%.
Foodborne disease is not showing the same pattern. This is evidence from the CDC where they, look, they're looking at comparisons between 2006 and now. And you can see that while some have no change and some diseases go down, other diseases go up, and there have been similar findings from the European Community.
Where on the, on over the past couple of decades, while there have been some dramatic successes, on the whole, there have not been a dramatic downturn in foodborne disease. And there are some reasons why foodborne disease should not behave like classical infectious diseases such as tuberculosis or malaria. The main one is that foodborne disease.
Is very much associated with the way food moves along value chains from farm to fork. And what we're seeing in developing countries is a massive urbanisation, a massive expansion of value chains, and a big increase in the consumption of risky foods, animal source foods and vegetables. This graph shows you how consumption in risky foods is changing in developing countries.
And you can see that eggs, meat, vegetables and fish are strongly trending upwards, whereas pulses, a staple food, the legumes are trending downwards. So this increase in consumption of risky foods, and this change in value chains to supply. Urban consumers with risky foods means that more hazards are getting into the value chain, and there's more chances for people getting infected.
I think if you use a thought experiment, I think you can see that in a, in a rural setting where a family perhaps eats one chicken a month, and the chicken is kept in the backyard, and then it's taken in in the morning and it's killed in the kitchen and it's put in the pot and it's eaten at lunchtime, but there's not a whole lot that can go wrong in terms of food safety. Now you compare that when you have an urban population demanding poultry but unable to afford a whole chicken, so they're buying chicken on skewers or are ready to eat chicken on the street, and that chicken is being raised in very unhygienic conditions in peri-urban settlements, crowded with people and other animals, and it's been killed in a very unhygienic slaughterhouse and then moved through complicated areas. To, to cities, that that leads to many more likely problems with food safety.
So foodborne disease, in developing countries, mainly caused by microbial hazards, although people are most worried about chemicals. The foods most implicated are animal source foods for which veterinarians have a responsibility in ensuring it's safe. And while most infectious diseases are happily trending down, foodborne disease is unfortunately trending up.
That brings us to the 4th and final section on managing foodborne disease. Managing foodborne disease is probably at a much less advanced stage than the other things I've been talking about. It's probably to, to, to use a veterinary analogy.
Our diagnosis of foodborne disease, understanding what causes it. Is relatively good. Our prognosis, understanding where it's going and what are the trends and drivers, is not so bad, but as therapeutics, our ability to manage foodborne disease in mass markets of developing countries is extremely lagging.
So what have we learned? Let's us start with the things which don't work. There's a tendency with which we definitely see in developing countries, to think that what we need is more rules, stronger enforcement.
People default to rules and enforcement. But these are informal markets. Most of the risky foods, more than 90% of the risky foods, are sold in what we call informal markets or traditional markets or wet markets.
So this is, if you like, everything which isn't modern retail. There's a small amount of food in developing countries which are sold in supermarkets and in what might look like modern shops, convenience shops. But the great majority is still sold on the ground, on wooden stalls in open air markets in the street by hawkers going round from door to door.
These are the informal and the traditional markets. And in these markets are largely regulation does not matter, and inspection hardly occurs. And when we do our surveys and look at what's happening in these informal markets, we find that food contains a lot of hazards.
For example, in milk, 100% of milk did not meet standards. In Nigeria, 98% of beef didn't meet standards, 52% of pork in Hanoi, 92% of milk in Addis, 36% of farmed farmed fish in Egypt, sorry, 30% of chicken from commercial industrial farms in Pretoria. And 24% of boiled milk.
This isn't raw milk, this is boiled milk did not meet standards. One thing we sometimes say to people is that when 3% of your milk doesn't meet standards, you have a problem with your milk. But when 90% of your milk doesn't meet standards, you have a problem with your standards.
So what we are seeing in developing countries are fairly advanced standards and regulations, largely taken from rich countries, but they are not being implemented. The standards are on the books, the implementation is not happening. Well, can we modernise our way to food safety?
Often policymakers and sometimes donors think that the problem is to do with the, with the, the smallholder dominated traditional farming system. And as I said, this informal retail system where, where food is being sold without refrigeration on wooden tables or, or in the street. And there's sometimes a, a belief that if we can switch over to the sort of food safety we have in, in, in, in UK or in Germany, where most food is sold in modern retail, with coal chains in place and, and relatively high levels of hygiene, things will be better.
And undoubtedly food safety is and foodborne disease is much worse in developing countries. Of the global burden, 98% is borne by by poor countries and only 2% by rich countries. However, work by Iri and others suggest that modernization can also be problematic.
For one thing, these traditional markets are extremely persistent. There was a, a belief around 10 or 20 years ago that supermarkets would just take over the food retail in, in Africa and Asia, as it has done in Europe and in Latin America, but that hasn't happened. And one of the reasons is that food sold in modern retailer retail is still much more expensive than food sold in traditional markets.
And also, traditional markets are close at hand, people like them, there's a lot of trust. There's a lot of reasons why these markets to persist. Another worrying issue is that whereas in rich countries, modern retail food is, with its problems, usually pretty safe.
In developing countries, that is not always the case. And also, the modern business models tend not to work so well in developing countries. So just to give you an example, this is another study we did in Vietnam, where we compared the, the level of safety.
We compared the compliance with standards in pork salt in supermarkets, pork salt in wet markets, and pork salt in the village in the old fashioned way. And I think you can see that the purple supermarkets were actually had worse. Food safety than the traditional markets did.
This was very surprising when, when we told it to people, but we think it is because in the wet market, basically the pig is killed in the morning, taken to the tall by 6 o'clock a.m., sold by 100 a.m.
And cooked and eaten by noon. Whereas in the supermarket, the pork sits in a chill cabinet where the temperature may go up and down for 3 or 4 days, and perhaps there's a power outage when the electricity goes off. So there are some risk mitigation which happens in an informal market, which doesn't in supermarkets.
And again, when you modernise and things go wrong, things tend to go badly wrong in a much messier way than if you never modernised at all. This was a modern, a modern slaughterhouse. Installed in Nigeria with off the ground chain slaughtering and, and, and very good conditions when it was installed.
But when it had been several decades in use with no investment in maintenance, this is what you get, a very muddled, crowded area where probably if an animal was just being killed under a tree in a village, it would have been safer. So, we said regulation can't do it, and modernization may not do it, can good practises do it? Can training do it?
And this is probably the default development intervention that only we will train people, raise awareness, have good practises, then the food will be safe. And there's some evidence beneath this. I mean, we do say in food safety, we often, many people are well-intentioned but ill-informed.
Many actors are well-intentioned but ill-informed. So if you just give them more information, they will change their behaviour. And indeed, several pilots focusing on training and good practises have shown improvements.
And when we look at export chains where good practises are needed, if you want to export your beans, your Kenyan beans to Tesco and sell it in the UK, you need good practises and safe food, and smallholders will learn some good practises and will improve their information. The difference between the export, where we show good agricultural practise really works, and the domestic, is that in the export, there are strong incentives for people to put their practise into action, because if you sell your your produce to an export chain, you get a very high premium, but the export chain tests very rigorously, and if your produce is not safe, you will not be allowed to sell. Unfortunately, in domestic markets, these incentives are not in place.
You can sell unsafe food and nobody knows, and you can, you will not be punished for selling unsafe food. So you do all your good practises, but you don't see any reward, and good practises have a cost to you. So when we see the good agricultural practises which have been so successful in allowing countries like Vietnam to export fish and Kenya to export produce and horticulture.
They don't work in domestic markets. In 4 years in Vietnam, GAP reached less than 1% of people, and in Thailand, the farmers had no better use, even if they participated in GAP than they didn't. So good practises are needed, but no no change will be seen unless there is incentives for behaviour change, or what we sometimes call choice architecture.
So what does work? If all these things don't work, if regulations don't work, and modernization doesn't work, and training people and good agricultural practises doesn't work for domestic markets, what does work? Well, we recently conducted a systematic literature review looking at food safety interventions in sub-Saharan Africa, and we identified more than 100 interventions.
We looked at interventions in, in two ways. One is along the value chain, so either at farm level, processor level, retail level, consumer level. Or government, regulation of value chains, but then also at the population level.
So these are more classic, public health interventions which target communities. And that would include things like medical interventions such as vaccination for cholera or dietary diversity to reduce exposure to aflatoxins. And along the value chain, we, we looked at different types of interventions, we were able to see different types of, of approaches.
One could be new technologies. So for example, introducing chlorine disinfection for chicken carcasses and slaughterhouses. Training and information, as I said, very popular where you gather farmers together and you, you give them training and how to perhaps carry out milking in a hygienic way.
And give them information on, on why if you don't milk hygienically, you will introduce bacteria into the milk. You processes and, and here there's interest in things like, for example, boiling milk to reduce contamination or, or sun drying fruit and vegetables. Organisational arrangements, that's looking at how value chain actors interact with each other.
So for example, outgrower systems whereby a supermarket may contract with a number of farmers that they will supply them directly with milk or, or with Eggs, and that brings in different ways of working. Regulation, which is the fallback of governments, they spend a lot of time doing regulation and writing regulation and not very much time enforcing it. And then infrastructure, which is provision of things like coal chain roads, rural electricity.
The arrows that the, the crosses indicate how much effort has been spent on these different areas. And what's probably of interest is that some areas have been very much neglected. Others have been quite a lot invested in, and there has been very little attention on incentives.
So very little attention on market-based interventions. However, the findings of the literature review were quite positive. Often when we do these systematic literature reviews, we find that only a very small percentage of things work.
This literature review found that quite a large percentage of things worked. And that included things like methodological approaches, risk-based, using HASA, appropriate tech. Technologies using milk cans instead of plastic jerry cans, using disinfectants, novel technologies such as ALSafe, which is a way to reduce aflatoxins by biological control, programmatic approaches, training street traders, zoonosis, targeted campaigns to control brucellosis or cystic sarcosis, very highly successful in Latin America, policies creating and enabling environment.
And market-based solutions, looking at willingness to pay. That all sounds very positive, but the bad news was that though effectiveness was often shown, there was almost no evidence on economic cost effectiveness, and nor was there any evidence on either the scalability, that is, could it spread out beyond the project and the sustainability? Would it continue after the project ended?
And in fact, the evidence suggested that most of these were pilots. And they were not sustainable or scalable. We have a saying in development, pilots never fail, and pilots never scale, which means you need to go beyond the one study written up in a journal article into a scalable solution.
So what does seem to work at scale? Well, the, we have found just a couple of islands of excellence of promising approaches, and I'm just going to highlight a couple of these now. Some of, one of the better documented is where we worked with milk vendors, informal sector milk vendors in Kenya and in India, where they were trained.
They got new technologies which were things like lactometers to, to measure the quality of milk and proper milk containers, which could be easily disinfected. They had incentives in place. They had reasons to change their behaviour.
In Kenya, that was because if they were trained and got a certificate, they were no longer harassed by the government, and they were able to to have better profits. And in Assam it was again they had better relations with the government and were able to negotiate for things in their interests. Economic studies showed that there was a high benefit.
Both of the projects have been finished for more than 5 years, but yet in both cases, the results are still seen on the ground, with a high number of traders involved and with millions of consumers benefiting. So, only a case study, but still, it shows it can be done in mass markets in developing countries. And this same approach now is being extended to meat.
And here's an example for, from Uganda, where again, you see a very unhygienic slaughtering conditions, where we worked with the large amounts of faeces, contaminating pigs, not, and leading to risks. We worked with the slaughterhouse managers. We developed a biogas whereby all the faeces could be instead used to generate electric generate heating and heat waters.
This led to savings, in having to cut down trees and savings and having to pay for wood. And then the butchers were trained, and this led to an improvement in the meat, which benefited large numbers of consumers. And again, a lot of this training was, was low cost, simple, appropriate technology, translating information into local languages.
This is a poster in local language on cystic sarcosis, using the WHO 5 keys to save for food, developing simple, simple hygienic ways of washing hands without contaminating the water you use to wash your hands. We summarised our findings on what works in informal markets and what we call the three-legged stool approach, and that says there are 3 essentials to get food safer. The first is pull.
There must be a demand for safer food. There must be incentives for safer food. Value chain actors must have some reason for changing their behaviour.
The next is push. Value chain actors must have the capacity to respond to demand, and that's where the training, the technologies come in. Training technologies by themselves won't work, but neither will demand for food safety.
The two need to go hand in hand. And then the third leg of the stool is the enabling environment. The government, the the regulators need to put in place the regulations and infrastructure that will allow the value chain actors to produce safe food in response to demand from consumers and others.
At the moment, we're testing this approach in in several different countries, including Ethiopia, Cambodia, Vietnam, and Uganda, and what we're hoping is to come up with an approach. This is a wide range of actors, I is involved, but many other universities, many other donors, many other development agents are, are all part of this big push on food safety, and we hope that in a couple of years we will be able to come back with some good methods which will start reducing this huge burden of foodborne disease. So the take home messages, foodborne disease is enormously important for health and development.
There is a huge health burden. It is comparable to the health burden of HIV AIDS, tuberculosis. Or or malaria.
And upcoming findings are going to show that this burden is even higher than we thought. Most of the burden is due to microbiological hazards, and most of it comes from the fresh foods sold in informal markets which predominate in poor countries and will predominate for decades to come. We find that hazards and informal markets are almost always high, but the risks are not always so high.
As I mentioned, you may have a lot of bacteria and milk, but if 99% of people boil their milk, then people are not necessarily getting sick from their milk. Moreover, that perception is a very poor guide, and that what people worry about and what makes them sick and kills them is not the same. There is the slightly worrying news that foodborne disease is likely increasing, and as such, it's going against the trend of other infectious disease diseases in developing countries which fortunately are going down.
We've argued and shown that there are no proven approaches for mass markets in low and middle-income countries that are scalable and sustainable. We do not have a solution. We have some promising ideas, but we don't yet have a universal solution.
However, there are some islands of excellence and areas under research which show good potential in reducing the huge burden of foodborne disease. Thank you for listening. More information will be online and we will be very happy to follow up, with any questions or comments on this important area of foodborne disease in informal markets.
