More than a decade ago, David Dodson was running an auto parts retailer in Massachusetts. Then a brief trip to Honduras with his wife, Stephanie, changed his career — and his life. While traveling through the country, they were shocked to find hundreds of children suffering from neural tube defects. In the United States, these defects are rare and preventable; women just need to consume small amounts of folic acid (vitamin B9) during the first few weeks of pregnancy. But in parts of Honduras, where this essential nutrient isn't always available in the food supply, neural tube defects are common and can lead to mental impairment or death. In fact, they're among the most prevalent birth defects in the world.
The Dodsons returned to the United States and started Project Healthy Children, a nonprofit originally targeted to help fortify food with folic acid to benefit Honduran children. The couple has since split, but they continue to work for PHC together and have expanded the organization's reach and mission. Today, PHC's small staff is on the ground in five countries, where they conduct research, assist governments in passing food-fortification laws, help food manufacturers find financing, and offer advice on how to create reliable nutrient-monitoring systems.
These efforts have helped combat nutritional deficiencies in the urban locations where PHC operates. But conventional food fortification does not reach rural areas, leaving the populations there at risk. "You can pass all the laws you want, but you're not reaching the most vulnerable people," says Stephanie Dodson.
So six years ago, PHC began developing technology that they hope will help reach the 1 billion people with no access to centrally processed foods. The new device, created in collaboration with students from Stanford's Design for Extreme Affordability class and currently being field-tested in Nepal and East Africa, is an automated, one-size-fits-all dosifier that dispenses iron, folic acid, and vitamin A into cereal grains, and fits into any type of mill hopper. It costs just $500.
Thanks to a grant from FARM Fund, a social-entrepreneurship investment vehicle started by fellow Stanford GSB alum Thomas Bird, PHC is in the process of creating for-profit entity Sanku to commercialize the technology. If successful, it could fund PHC's food-fortification expenses — and the technology itself could reach more than 100 million people. "I know the number sounds incredible, but that's only 10% penetration," says David Dodson, who is president of PHC.
Ever since the 1920s, when a group of Michigan scientists persuaded the American sodium industry to add iodine to common table salt, a variety of foods in the United States have been fortified with small, tasteless traces of essential vitamins and minerals: zinc and folic acid, iron and vitamin A. But in the developing world, food fortification is less widespread. The average diet doesn't provide a sufficient amount of essential vitamins, and a number of nutritional deficiencies remain common — even in communities where people have enough to eat.
Hidden Hunger: a Global Phenomenon
This phenomenon, known as hidden hunger, affects a staggering number of people. According to a 2009 study by the World Bank and UNICEF, among other organizations, roughly 18 million children a year are born mentally impaired because their mothers didn't consume enough iodine, a million people die annually due to lack of vitamin A, and nearly half a million children under the age of 5 die each year due to an insufficient amount of zinc in their diets.
People can get these nutrients from vitamins, but analysts say food fortification is a far more efficient way to prevent potentially deadly nutritional deficiencies. Not only is it safe, but depending on the nutrients in question, food fortification costs between 5 and 25 cents per person annually. In other words, the potential gains far outweigh the costs. According to the World Bank, nutritional deficiencies in vitamin A, folic acid, and iron cost Tanzania, for instance, more than $500 million a year. That's nearly 3 percent of the country's gross domestic product. "The cost effectiveness is ridiculously low," says Stephanie Dodson, who is currently chair of the PHC board.
Efficiency is what initially attracted them to food-fortification efforts. It seemed that making a difference would be easy. David, Stephanie, and their colleagues experimented in Honduras with various lobbying strategies and researched which types of foods were the best to fortify with folic acid. They learned a lot, but decided the organization wasn't being effective enough.
In 2005, they shifted direction. David says they realized that when people donate money, it's coming out of their charity budget, which is generally finite. If other charities were being more effective than PHC, he decided, his organization should no longer solicit donations.
"We had to be convinced that our charity was comfortably in the top third of charities," he says. "And that meant it had to be sustainable, that our results could be measurable, scalable, and cost-effective."
This realization started taking shape when Dodson visited a pediatric intensive care unit at a small charity hospital in northern Honduras, filled with hundreds of children in metal cribs. There were no electronic monitors, and the hospital was desperately short of staff. Mothers functioned as makeshift nurses for their children. Many lived at the ICU for several months at a time, sleeping on the cold floor beneath the cribs. As he stood in this crowded room, Dodson noticed a man leaning over one of the cribs and asked him why he was there. The man pointed to a baby girl. "This is my daughter," he said.
The man had been there for weeks, while his wife worked and cared for their three other children. He had lost his job because of the time he had spent at the hospital, but seemed remarkably composed. "This is just what fathers do," the man said.
Dodson, who has three daughters of his own, began to cry. "It made me realize that moms and dads are the same no matter where you go," he says. "If I had been born where he was born, I would have been in that hospital, not him. The playing field is so horribly tilted, and I have just been on the lucky end of it."
Vowing that Project Healthy Children would no longer be just a hobby, Dodson started giving PHC a radical reboot. He and the team decided that PHC needed to expand and become a cost-effective consultant and lobbyist dedicated to teaching government and industry how to fortify a variety of foods with a host of nutrients, and establish a way to monitor the results.
In 2008, PWC went into Rwanda, a nation where anemia affected nearly 50 percent of children and 30 percent of women of reproductive age. Despite widespread salt iodization, roughly 25 percent of school-aged kids were affected by goiter, a thyroid disease caused by a lack of iodine. Working with Rwanda's Ministry of Health and other government agencies, PHC quickly analyzed which foods were best to fortify, such as wheat, maize flour, sugar, salt, and cooking oil. It then figured out the right amount of nutrients to put in each and advised the Ministry of Health to issue a decree making food fortification mandatory for all products purchased by the government. Once that happened, the nonprofit began advising food manufacturers on how to comply with the law and set up a strong monitoring system, a process that is ongoing.
Elsewhere, things did not always go as smoothly. In the late 2000s, PHC lobbied the Honduran government to create a law that would give the Ministry of Health the power to make food fortification mandatory and set up a system to monitor changes in the population's diet. But in the summer of 2009, the country found itself in the grip of a constitutional crisis and a subsequent coup. Congress did pass a food-fortification bill in 2010, but the legislation, which was signed into law in 2011, wasn't comprehensive enough, according to David Dodson. As the country became increasingly mired in corruption and drug-related violence, food fortification simply wasn't high enough on the agenda of Honduran politicians, he says. "I think we had an impact there," he adds, "but not a huge impact."
One of the ways to ensure that PHC will have a lasting impact, Dodson says, is having a plan to walk away. When the team retooled PHC, one of the goals was to make sure the organization goes into a country with a definitive goal and end date. "We thought it was a good idea to have a finish line to prevent what can often happen with nonprofits, which is that their unstated mission becomes just perpetuating themselves," he says. "We decided that we're going to turn out the lights in seven years, and in the meantime, we'll get our work done fast and furious."
By 2017, PHC hopes to have reached 70 million people in seven countries through conventional food fortification, and as many as 100 million through small-scale fortification. It is well on its way. By year's end, PHC will have completed its mission in Rwanda and Malawi, where its food-fortification efforts have reached 15 million people. "That's our biggest success yet," Dodson says. In other words, PHC is halfway home.
David Dodson graduated from Stanford in 1983 with a degree in economics, and in 1987 received his MBA from Stanford Graduate School of Business, where he is now a lecturer in management.
Stephanie Dodson received her MBA from Stanford GSB in 1988.
Thomas Bird received his MBA from Stanford GSB in 1988.