By Charitha Ratwatte –

Charitha Ratwatte

Malnutrition will cost the world US$ 125 billion

The politician responsible for national health care of the people has gone on record saying that over 20% of the population appears to suffer from malnutrition. He was speaking at a Pulasthi Knowledge Foundation event in Polonnaruwa.

Recent research by Save the Children in Ethiopia, India, Peru and Vietnam that infants who do not receive the necessary nutrients in the first 1,000 days of life, from conception to their second birthday, will suffer from developmental brain deficiencies that hold back their learning ability. This will cause a serious obstacle to the progress, both social and economic, of countries and communities suffering from severe malnutrition.

The Save the Children studies monitored 3,000 cases, showed that children who were malnourished scored 7% lower on maths tests and were 19% less likely to read a simple sentence by the time they were eight years old. They were also 12% less likely to be able to write a simple sentence and 13% likely to be in the correct grade in their school.

Save the Children points out that the problems of malnutrition have been ‘under-recognised and underappreciated’ by nations and communities which have traditionally relied on small holder small scale agricultural holdings and lower skilled sectors at the bottom of the economic ladder. This certainly seems to be the problem we are having.

It is not that people who are malnourished and stunted will not be able to get through a basic education; most of them will do so. But as countries need to improve the skills of the workforce into more technical and technological fields, limitations of capacity will emerge. Certainly at hi tech and tertiary levels there would be huge drawbacks. There will be a real constraint to a population’s enhancement of skills and capacity.

Tackling malnutrition: Pitifully slow progress

At a recent Global Nutrition Summit, it was stated that progress in tackling malnutrition has been pitifully slow when compared with the other Millennium Development Goals. Save the Children reported that, for example, overall progress in improving children’s education has been 32%, but nutrition has improved only 13%, since the mid 1990s.

A Consultant Medical Nutritionist at Colombo’s Medical Research Institute disclosed some time ago that 0.38 million Sri Lankan children under five years of age were stunted. She also stated that 0.2 million or one in nine children are wasted, being below normal weight for height, 0.4 million or one in five underweight and 0.24 million are suffering from obesity.

There about one million people who are unable to consume three meals a day; 0.3 million of these are elderly people. Four million people, that is one-fifth of the population, are anaemic. One in five or 0.8 million women are underweight, while one in four, that is nearly 1.3 million women, are obese. The issue is further compounded by the fact that currently Sri Lanka is well below replacement levels for population growth indicators. Our birth rate is 0.7 while the minimum required for a population to replace itself is 2.1 children per woman.

When the number of children a woman can expect to bear in her life time falls from the high levels of three or more to a stable rate of two, a demographic change surges through the country for at least a generation. Children are scarce, the elderly are not too many, longevity has not yet set in the death rate being high and the country has a bulge of working age adults.

Currently all labour intensive industries in Sri Lanka are facing manpower shortages. We have probably passed the demographic dividend time frame. This is compounded by large numbers immigrating for employment to West Asia, Korea and other labour importing countries. Large numbers who were recruited into the armed services, before the war ended, being kept in uniform and deployed on construction, maintaining parks and other projects, and the expansion of Government employment has also taken away potential employment capacity in the labour intensive sectors such as agriculture, fisheries, plantations and industries like the garment sector, which is making a great virtue of being able to successfully retain its machine operators. Already in the construction sector, it is reported, large numbers of work visas have been issued to foreigners from East Asia.

Urgent change needed

So not only do we have diminishing numbers of people of employable age, we also will have more of them stunted and intellectually challenged. The resultant skills ‘mismatch,’ as pointed out by Save the Children, the gap between what the process of education and training provides and what the labour market demands, also makes the problem worse.

To enhance the capacities of the fewer children, the process of education and vocational training needs urgent change. Science, Math and English have to be taught in all school. Participation in extracurricular or co-curricular activities, sports, the creative and performing arts, the crucible of creativity, must be encouraged, students must be encouraged to do independent research and presentations and argue and debate positions, to think out solutions, to surmount challenges. Vocational and technical training must be brought under the discipline of the market.

Urgent steps need to be taken on addressing the nutrition angle, as the reasons for the declining birth rate are not ones that can be easily changed. With more women literate and having the capacity to control their own fertility, with the means for such control being freely available, at one time, by a subsidised healthcare delivery system which reaches out to all parts of the country, with more women in the work force, postponing marriage, having children later in life, there are now reports of this being curtailed.

However, social pressures are difficult to change in the short term. Children will be fewer in number and with child survival rates being high, families end up being nuclear, parents plus two children or less; we have the example of China’s one child policy and the ‘Little Emperors!’

The birth rate will, if at all, go up again, taking trends from the developed world as a model, only where economic conditions allow mothers to stay at home to bring up children, a single parent’s income could support the family, where paid help for child care is available freely, where day care and crèches for children are available suitably supervised, regulated and monitored, where facilities such as paternal leave in addition to maternal leave is available to parents who have a young child. Sri Lanka will not have these facilities for some time.

Therefore the only viable solution is to take some aggressive steps to tackle the problems of malnutrition. 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%, leading 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.

Sri Lanka is 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.

Policymakers baffled

Some years ago also, the politician responsible for health had 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 overweight, 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. Over 20% of Sri Lankan women are overweight and the trend is increasing.

There is a clear correlation between nutrition and poverty, so with poverty levels supposedly going down, malnutrition should also reduce, in theory. The conundrum is the crisis on the ground does not reflect the theory! It’s the converse of the crack about the Economist, who is puzzled as to why what works in practice does not work in theory! Handing out of free nutrition supplements like Thriposha which are often misused and mis-targeted is not the answer.

Delivery of nutrition services

Fortunately Sri Lanka has a well proven model for the delivery of nutrition services. 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 underweight 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 and cleaners, it is a bureaucratic nightmare for DMOs.

Some remote areas hardly get deliveries, as was emphasised at the Polonnaruwa function by the politician responsible. Mothers turn up for the clinic and go away frustrated. The system punished success, a successful mother whose baby’s nutrition improves and the positive progress is marked on the age for weight chart at the nutrition clinic is deprived of food supplements!

Four successful strategies

The JTF Nutrition intervention’s success was based on four new and important strategies.

(1) Involvement of community organisations, which have delivered development packages to poor communities with no disciplinary 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 highest 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 well being, 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 scorecard to enable the participants to monitor their own household scores and support was provided to take initiatives which would help to improve the score, for e.g. 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, preschools, 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.