War against malnutrition: Unwinnable? - The need for an integrated program on a war footing
The need for an integrated program on a war footing
In 2008, eight prizewinning economists were asked to list the type of projects which would do the most good for the most number of poor people, if they had an imaginary $ 75 million to spend. Half of their proposed projects involved nutrition.
There has been an increased awareness of the dangers of malnutrition and the fact that by targeted interventions these dangers could be reduced and eliminated over time. In 2010 donors, charities and companies drew up a policy guide line called Scale-Up Nutrition (SUN).
The Word Bank has published a book entitled ‘Repositioning Nutrition as Central to Development’. Save the Children’s avowed policy is ‘galvanising the political leadership’ to support the campaign.
The Oxford Advanced Learners Dictionary (8th edition) definition of malnutrition is: a poor condition of health caused by a lack of food or a lack of the right type of food. Malnutrition in infants and children results in underweight babies and stunted growth, deficits in height for age in children and deficits in weight for age.
Malnutrition and poverty
Researchers have decisively linked malnutrition and poverty, the one feeds the other and vice versa. At a conservative estimate malnutrition is said to bring about GDP losses of at least 2-3 %, lead to a potential reduction in lifetime earnings for each malnourished individual.
Stunting among children is linked to a 4.6 cms loss of height in adolescence, 0.7 grade loss of schooling and a seven-month delay is starting school. Clearly improved nutrition is a driver of enhanced economic growth. Paradoxically, rapid weight gain after the second year in a child has been linked to impaired glucose tolerance and obesity, in turn linked to lifetime diseases such as diabetes and hypertension.
Nobel Prize for Economics Laureate Amartya Sen has based on his childhood experiences with the Bengal famine in colonial India, long argued that what really matters is to overall supply or availability of food, but the individuals access to the food. The Ethiopian famine of 1984 proved his point beyond any doubt.
The old paradigm of donors shipping food to areas where there has been crop failure has today been replaced by attempts to help people obtain food by reducing poverty and making markets more efficient.
Further it is not volume of food alone, quality matters. Calories and micro nutrients are important, it is estimated that over two billion people suffer from lack of these. There are over a billion people who are obese, in that they eat too much of unsuitable foods. The fact is that out of a world population of seven billion, approximately three billion eat too little, too unhealthily or too much.
Sri Lankan example
Let us take Sri Lanka as an example, although it is one of the better performers in South Asia. For a middle income country, Sri Lanka’s maternal mortality of 46.9 per 100,000 live births, infant and under five mortality rates of 13 and 15 per 1,000 live births and life expectancy at birth, 73 years, are good world class indicators.
But under nutrition, 29% underweight is high. This is the measure of non income face of poverty, proportion of people who suffer from hunger. It has two indicators, the prevalence of underweight among children under five and proportion of the population below a minimum level of dietary energy consumption.
The first of the eight Millennium Development Goals is to eradicate poverty and hunger by 2015. Sri Lanka, a MDG study concluded, may be among countries able to achieve several of health MDGs, and the income poverty MDG, under certain conditions, i.e. to halve the proportion of people living on less than a $ 1 a day, but not the non income poverty target, the nutrition MDG.
Recently Meera Shekar of the South Asia Division of the World Bank, in a presentation on Scaling-Up Nutrition (SUN) in South Asia, stated that worldwide 29 countries have alarming levels of malnutrition, primarily in Asia, Africa and Latin America.
In five South Asian countries the percentage of underweight children among the under fives, are over 40 % taking into account data from 1960 to 2007; for Sri Lanka, one of the better performers, it reduces very gradually from 38% in 1977 to only 21% in 2006. This is with our other social indicators being at virtual First World levels!
One of Sri Lanka’s Ministers of Health has gone on record that ‘policymakers are baffled, as they cannot pinpoint the cause for weak nutritional levels in mothers and children’. Sri Lanka is, paradoxically, faced with double jeopardy of both under nutrition and obesity, which is on the rise, among high income groups and this makes the population susceptible to the high risk of cardiovascular diseases, diabetes and other non-communicable diseases.
The National Diabetes Centre of Sri Lanka recently reported that a study has revealed that 24% of adolescents had two or more risk factors which could lead to the future development of Type 2 Diabetes. Over 20% of Sri Lankan women are obese and the trend is increasing.
Under nutrition in Sri Lanka affects very young children and mothers, often during pregnancy, leading to low birth weight. The early damage caused to children’s cognitive and growth potential, in the 1,000 days from conception to 24 months, is tragically, irreversible, whatever is tried as remedies thereafter.
The window of opportunity for improving nutrition standards is very small. It ranges between the pre-pregnant mother and until the newborn is 24 months old. Recent research shows that a large part of the damage is caused to the foetus while in the womb, before birth.
The mother-to-be must be given supplements of multiple micro nutrients, iron foliate, and iodine through iodised salt, calcium supplements and protection from air pollution caused by cooking fires. For the newborn baby, compulsory breast feeding. For the baby and child, improved supplementary feeding, zinc supplementation, zinc in management of diarrhoea, vitamin A fortification and supplementation and insecticide-treated mosquito nets. The interventions are known; the delivery is the problem.
JTF Nutrition intervention success
Fortunately Sri Lanka has a well-proven model for delivery. The Nutrition Fund of the Sri Lanka Poverty Alleviation Project, funded by the World Bank (CREDIT 2231-CE) managed by Jansaviya Trust Fund (1991 to 1998) focused on training mothers to recognise malnutrition in them and their children, sensitised them to long-term debilities which it caused and trained them to prepare more nutritious foods to combat malnutrition.
The Director of Nutrition Fund Dr. Priennie Ranatunga and her team trained mothers to recognise under nutrition and to appreciate that a malnourished mother will give birth to an underweight girl child, who in turn, due to lack of nourishment, will give birth to malnourished children, in the future and that it was within their power to take action to break this vicious cycle.
This is in stark contrast to the present method of distributing food supplement Thriposha, which is issued to pregnant mothers and under weight babies. In a poor household this is naturally shared among the whole family, if the mother is not sensitised of her and her child’s special needs.
Dr. Ranatunga trained mothers to plant, grow, harvest, produce and process their own alternative food supplements in their home gardens. Thriposha deliveries are never on time, poor pregnant and lactating mothers have to make repeated visits to the clinic to collect their allocation.
There is under supply and rationing, timely deliveries are constrained by factors like lorry availability and lack of funds for overtime for drivers, it is a bureaucratic nightmare for DMOs. Some remote areas hardly get deliveries. Mothers turn up for the clinic and go away frustrated.
Four new and important strategies
The JTF Nutrition intervention success was based on four new and important strategies:
(1) Involvement of community organisations, which have delivered development packages to poor communities with no discriminatory blinkers for decades in Sri Lanka. Their incisive understanding of the problems of the poor and their holistic approach to development (which includes even areas such as culture, values and spiritual development), gives them credibility and asserts their ‘interiority’, thus reducing the social distance between themselves and the people. By the end of 1994, around 40 community organisations had commenced in depth nutrition projects in about 160 Divisional Secretary areas.
(2) Innovative approach to human development. The greatest powers of a human being are those of ingenuity and creativity. Human development therefore requires that brain development proceeds unimpeded. The human foetus and infant (0-12 months), have the highest state of brain development; 3.5% of the brain being developed, it is estimated at around 3.5 years of life.
While brain mass is correlated to nutritional wellbeing, brain stimulation is affected by the child’s environment. The JTF’s Nutrition program used a simple ‘ weight/age’ index to measure nutritional status of children, trained mothers to source and feed children with supplements, and supported early childhood education.
(3) Quantification and use of indicators. Voluntary nutrition workers on the program carefully monitored the nutrition of status of children in the village, the access to pure water, the access to latrines, etc. and maintained a score card to enable the participants monitor their own household scores and support was provided to take initiatives which would help to improve the score.
For example, a community water supply scheme through the JTF’s own participatory Community Projects Fund. A baseline scorecard was prepared and communities shown how they could improve their score and at the same time attain higher mother and child nutrition scores, which were pre determined through participatory process.
(4) Implementation in a small homogenous geographic area. Community interventions have to be local. Interventions are multi faceted – adult education, pre schools, latrine construction and use, water supply schemes, agricultural wells, wells for drinking water, cultivating, processing of supplementary foods, etc. These have to be authentic and sustainable community efforts. A classic case of Schumacher’s ‘Small is Beautiful’. The approach of the JTF’s Nutrition program was participatory with bottom up planning and sequenced, realistic achievable stage by achievable stage.
The Implementation Completion Report of the World Bank, on Sri Lanka’s Poverty Alleviation Project , implemented by Janasaviya Trust Fund, (JTF) dated 15 June 1998, has this to say on Nutrition Fund intervention:
‘The activities of the Nutrition Fund were the most successful. It covered over one fifth of the population within the conflict-free zones of Sri Lanka, and was operational in 18 of the 25 Districts. About 68 Partner Non-Government Organisations were involved, in over 1,600 Grama Niladhari divisions, with a beneficiary participation of 89% of the target population. The outreach was approximately 700,000 mothers and 2.7 million children, well in excess of the Staff Appraisal Report target. Success can largely be attributed to innovative interventions focusing on behavioural factors. Reliance on participatory approaches succeeded in enhancing nutrition awareness and improving feeding practices.’
At the time of project closure, at over ¾ of the sites at which the Nutrition program was being implemented, serious malnutrition had been reduced by more than 15%, based on reporting and record keeping by the participating community organisations.
This model clearly worked. Sri Lankan women, especially the young, are literate. They can be reached by news papers, radio, TV. The grandmother, mother and girl child should be targeted by an aggressive outreach program if this cycle of under nutrition, malnutrition and irreversible damage to children’s cognitive and growth potential is to be broken.
Sri Lanka’s current problems on child and maternal malnutrition, are further compounded by fact that a healthcare system, infrastructure and budget, which has evolved to respond to health hazards caused by communicable diseases, in a young population, is today struggling to treat a rapidly ageing population suffering from non communicable diseases and other geriatric illnesses.
But any overhaul is a political landmine, taking on all the vested interests which no politician, in survival mode, interested in popularity and short term fixes for victory, in a five- to six-year electoral cycle, will ever dare to touch.
World war against malnutrition
Internationally, there has been some concern expressed on the world war against malnutrition. Bill Gates, founder of Microsoft, has publicly accused UN agencies of allowing infighting, inefficiency and parochial interests undermine the battle against malnutrition.
The UN has three agencies devoted to his aspect of human development, the Food and Agriculture Organization (FAO), International Fund for Agricultural Development (IFAD) and the World Food Program (WFP). Gates accuses these agencies of not working together in a focused and coordinated way.
However, change may be on the way. Activists have hailed the appointment of Jose Graziano da Silva, who headed Brazil’s highly successful Fome Zero (zero hunger) program, has been appointed to head the FAO. The success Fome Zero has proved that the war against malnutrition must be coordinated: it is a program covering conditional cash transfers, to irrigation, and help for smallholder farmers.
As Lawrence Haddad, Director of Britain’s Institute of Development Studies says: “Malnutrition reduction needs powerful champions who know how to get things done across government, avoid gobbledygook and finish the story.” The battle must be integrated, better sanitation, increase dietary variety, vaccination, increase best feeding of babies, scale-up maternal health programs, teaching of good feeding practices , accurate targeting of the poor, and by measuring and monitoring the progress.
Sri Lanka, in particular, to win the war against malnutrition, will require strategies to:
(a) Reduce income inequalities
(b) Improve access to safe water and sanitation
(c) Reduce food insecurity
(d) Scale-up direct nutrition interventions
(e) Use the successful participatory delivery mechanism well proven in the Janasaviya Trust Fund’s Nutrition Intervention and
(f) Revise and reform the Government health care expenditure and infrastructure to reflect the preventive and curative health demand realities of today. To solve the malnutrition problem, there is a well proven delivery system for the necessary interventions.
The question is, will we muddle through in the confusion that persists or have we the political will to cut across parochial bureaucratic/medical vested interests and implement an integrated program to win the war against malnutrition?
(The writer is a lawyer, who has over 30 years experience as a CEO in both government and private sectors. He retired from the office of Secretary, Ministry of Finance and currently is the Managing Director of the Sri Lanka Business Development Centre.)
