Malnutrition and the First 1,000 Days

Let’s start with the big picture – every year, nearly 7.6 million children will die before they turn five years old (UNICEF). That’s 7,600,000 children, just shy of the total population of a country the size of Israel, or Honduras, or the entire combined populations of Kansas, Nevada, and New Mexico. Imagine the scale of this problem. Imagine if EVERY year, these countries or states saw their entire population wiped out – each and every year, over and over again. Except it’s not an entire population, but exclusively the most vulnerable members of human society – poor children who aren’t even five years old yet.

This is, unfortunately, the world we find ourselves currently living in hard as it may seem. It is worth pausing here to note that the under-5 mortality (a measure of the probability of dying between birth and five years of age per 1,000 live births) is at its lowest ever, historically. We have a lot to be proud of in terms of how far we have come in the past half century below as the graph below indicates:

According to Save the Children’s State of the World’s Mothers 2012 (and can be found here), malnutrition is an underlying cause of death for nearly 2.6 million children each year. Malnutrition is a significant problem, not just because of the mortality rates it induces in young children and mothers but also because of the morbidity and suffering it causes to those who survive it. Every year, 20 million babies are born into this world with low birth weight, some because they are born too prematurely and others because of inadequate growth and nutrients while developing in the womb.

There are also economic factors impacted by malnutrition – adults who were malnourished as children earn an estimated 20% less on average over the course of their lives than those who weren’t. Imagine how quickly that adds up, and how cyclical that poverty trap becomes. Malnutrition can also cost developing countries an estimated 2-3% of their GDP every year, a significant amount for any country let alone ones grappling with severe poverty.

As might be reasonably inferred, malnutrition disproportionately affects the poor and disenfranchised. Across South Asia, “the poorest children are almost three times as likely to be underweight as their wealthiest peers.” That number becomes a lot more alarming in Latin America, where in countries like Honduras the poorest children are eight times as likely, or El Salvador and Peru where they are 13 and 16 times as likely to be underweight.

The report compares what a typical girl can expect between the highest and lowest ranked countries on their Mother’s Index list, which compares the well-being of mothers in 165 countries. The difference is stark:

“A typical Norwegian girl can expect to receive 18 years of formal education and to live to be 83 years old. Eighty-two percent of women are using some modern method of contraception, and only 1 in 175 is likely to lose a child before his or her fifth birthday. At the opposite end of the spectrum, in Niger, a typical girl receives only 4 years of education and lives to be only 56. Only 5 percent of women are using modern contraception, and 1 child in 7 dies before his or her fifth birthday. At this rate, every mother in Niger is likely to suffer the loss of a child.”

That level of suffering is beyond difficult to read – it is almost impossible to comprehend. The report goes on to state, point blank, that “Persistent and worsening malnutrition in developing countries is perhaps the single biggest obstacle to achieving many of the Millennial Development Goals (MDGs).”

Fortunately, Save the Children and other organizations have begun focusing on a set of interventions that could significantly improve the current malnutrition crisis. These are focused around a concept known as the First 1,000 Days, which is the period between conception and the start of pregnancy to a child’s second birthday. Research shows that adequate and sufficient nutrition in this window of time “can have a profound impact on a child’s ability to grow, learn, and rise out of poverty.” The report goes on to lay out the foundation for why we should focus on the First 1,000 Days:

“Mothers and babies need good nutrition to lay the foundation for the child’s future cognitive, motor and social skills, school success and productivity. Children with restricted brain development in early life are at risk for later neurological problems, poor school achievement, early school dropout, low-skilled employment and poor care of their own children, thus contributing to the intergenerational transmission of poverty.”

There are six key solutions with immense potential to save the lives of our children in their nascence, and well beyond. It is the intention of the author and this blog to dive deeper into the weeds and study different programs around the world to assess where successful programs are running, how they are able to do so, and the impact that has generated. For now, let us highlight in brief the six solutions:

1. Provide iron folate supplements to cure iron deficiency anemia, the most common nutritional disorder in the world. Anemia is a “significant cause” of maternal mortality and can cause premature birth and low birthweight. It is estimated that 25% of the world’s population, or 1.6 billion people, are anemic – the vast majority of whom are women.
2. Improve knowledge and practice of exclusive breastfeeding in the first 6 months provides comprehensive nutrition and immunity development for newborns against common childhood illness. Breastfed children are 6 times more likely to survive the early months of their life than non-breastfed children
3. Improve complementary feeding knowledge and practice, adding other foods and liquids to a child’s diet between the ages of 6-23 months of age.
4. Provide Vitamin A supplements to bolster the human body’s ability to counteract the debilitating consequences of diarrhea. Vitamin A deficiency affects nearly a third of all preschool aged children, which is a major contributing factor to diarrhea and measles, and can cause irreversible corneal damage.
5. Provide Zinc supplements along with oral rehydration solution to help children with diarrhea recover more quickly and protect them and their communities from recurrences.
6. Improve knowledge and practice of water, sanitation, and hygiene (WASH) best practices to prevent diarrheal diseases at the source, the cause of 1.3 million children deaths each year.

What is most impressive about all of these interventions is their relatively low cost (cents to a few dollars per individual), their track record of successful scaling, and their long-term payback on investment. For these reasons alone, we should look more closely at programs, organizations, and governments around the world that are implementing successful interventions based on these solutions, learn from their successes and mistakes, and replicate or scale up with additional resources.

Women’s Economic Empowerment, and Education

On to the inaugural post! Today I’d like to broach the topic of Women’s Economic Empowerment (WEE). In the world of development, this is as close to the Holy Grail as we have come to achieving true poverty alleviation. Its worth pausing for a moment to dig deeper into we actually mean by WEE. I have been reading through a terrific research report by the Overseas Development Institute (ODI) titled “Women’s Economic Empowerment: Navigating Enablers and Constraints” (by Abigail Hunt and Emma Samman) which you can find here. In it, the authors state the definition of WEE as follows:

“Women’s economic empowerment is the process of achieving women’s equal access to and control over economic resources, and ensuring they can use them to exert increased control over other areas of their lives.” (Taylor and Pereznieto, 2014).

While I think this idea really broadly covers the aspirations of WEE work, I think it’s a little vague and begs for more detail over how exactly control and access lead to increased empowerment. Critically, what emerges is the ability control and access have to generate power for social and economic change. The authors go on to refine their definition of WEE as a,

“Process whereby women’s and girls’ lives are transformed from a situation where they have limited power and access to economic assets to a situation where they experience economic advancement.” (Taylor and Pereznieto, 2014)

In my opinion then, the true value of WEE is the ability to not only provide control and access but also to seed transformative power changes in society at the micro (individual, household, familial, regional, etc.) and macro (economic, state-level, international) levels. The report continues to expand on 10 “key factors” that can enable or constrain WEE. I hope to get into most of these factors in the future but for now I want to focus on the first, and in my estimation one of the most important – Education and Skills Development.

I have really positive news to start with – most people fundamentally believe in equal access to good education for both boys and girls (OECD, 2012b; Jones et al., 2014b;Purewal and Hashmi, 2015)! This is really an understated achievement of shifting cultural norms, and is worth its own moment of pause and reflection. While this may be self-evidently important, I think a powerful statistic shared in the report elucidates why we should be concerned with equitable access to quality education as a transformative social justice practice: “An additional year of primary school for girls can later increase wages by around 10%, rising to 15-25% for each extra year of secondary school, and nearly 17% for tertiary education.”

But don’t dwell there too long because unfortunately we don’t actually see this professed equity play out in the real world. According to UNICEF, in 2013 there were nearly 63 million girls of primary or secondary school age who were not enrolled respectively around the world. That figure is nearly the entire population of France. So what exactly are the barriers to female participation and access to quality education?

The short answer is there are a lot of reasons. It would take hundreds of pages to go into the details for all of them so I’ll just mention a few along a micro and macro split. At the micro level, some of the most important causes include young/child marriage. For example, according to ODI’s research report Gallup notes that in 29 Sub-Saharan African countries in 2015 “…married girls aged under 18 with a secondary education was 16% compared to 36% of unmarried girls.” While both numbers are starkly low, one is significantly lower.

Another important reason mentioned in the report is a lack of household resources. This can range from lack of financial resources to purchase school uniforms, textbooks, notebooks and pencils, and even tuition fees. Furthermore, in places like India where I worked for several years on issues of primary school education, there is a distinct and unfortunate cultural preference to send boy children to school over their girl siblings when resources are limited. (Author’s Note: A further blog post will provide more substantial data and research to back this up, as well as personal observations from my own professional experience). Conversely, programs that aim to alleviate these financial burdens have seen interesting and hopeful reduction rates in dropouts for adolescent girls (Duflo et al., 2006). A few other considerations at the micro level include “institutions that are inhospitable to girls who are menstruating, pregnant, or have children, curricula that reinforce traditional gender roles and a lack of female teachers.” (UNFPA, 2014)

At the macro level, data suggests that while most people are negatively impacted by external shocks (economic crises, wars, famines, natural disasters, etc.), girls’ lives and access to education are severely affected. One of the most interesting and disheartening consequences of economic shocks occurs when household mothers are driven to pursue more paid economic activities. According to the ODI research report, “girls are often the first to be removed from school to take on extra domestic responsibilities, including looking after younger siblings.” The disproportionate burden that is placed on women and young girls to manage household and informal sector care is evident in school dropout rates in periods of economic contraction (Stavropoulou and Jones, 2013). Even worse we find that “4 of the 5 countries with the largest gender gaps in education” are facing war or insurgency.

I want to end with a reflection on what this last piece of information tells me. Something I think is becoming abundantly clear through the data is the tremendous improvements to WEE gained through the modern infrastructure of multinational cooperation and stability. Rash wars, interventions, or escalations of tensions not only damage nation-states and the infrastructure of international stability – they disproportionately affect women who are often the first to be stripped of the progress and advancements of the 21st century.

More on that later…thanks for reading.