The malnutrition time bomb

At a recent seminar held in Colombo in the premises of a leading policy research institute, a visiting foreign nutrition expert stated that the greatest danger for a country in having malnourished and anaemic women and children is that, in addition to the stunted growth, the brain development of babies in the crucial 1,000 days from conception to the child’s second birthday is irrevocably affected, resulting in a population which has serious limitations in intellectual ability and capacity.

He requested his audience to think of the consequences for a nation, and the world generally, when children of that stunted and intellectually-challenged generation become adults and take charge of the country’s future, its policy formulation and politics, its administration, its judiciary, and its police and military, its business and industries. It occurred to me that, when considering the chaos going on in the world, this may be one plausible explanation!

Nutrition crisis

A recent news item reported that a Consultant Medical Nutritionist at Colombo’s Medical Research Institute disclosed recently that 0.38 million Sri Lankan children under five years of age are 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 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. These numbers, while indicating a major current nutrition crisis, more dangerously, reflect a humongous time bomb in the capacities and capabilities of future citizens of this country.

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 0.93 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 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 with the death rate being high and the country has a bulge of working age adults.

Demographic dividend

Economic growth can blossom with this demographic dividend with the correct policies. Currently all labour intensive industries in Sri Lanka are facing manpower shortages. We have probably passed the demographic dividend timeframe.

This is compounded by large numbers emigrating for employment to West Asia and other labour importing countries. Large numbers being recruited into the armed services and Government service 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.

Ravi Fernando, who was one time Director of Corporate Branding & Strategic Corporate Responsibility at MAS Holdings Ltd., the largest supplier of intimate apparel, sports and leisure wear in Sri Lanka, has been quoted saying that “in an industry where the attrition rate was in the 20 to 35 per cent region, we brought it down to four per cent”. This had been done through an internal programme to empower the 80 per cent women employed in a 43,000 strong work force called ‘Women Go Beyond’.

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 skills ‘mismatch’ the gap between what the process of education and training provides and what the labour market demands also makes the problem worse.

Urgent change needed

To enhance the capacities of the fewer children, the process of education and vocational training needs urgent change. Science, Mathematics and English have to be taught in all schools. 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 and 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 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, fewer in number and with child survival rates being high, families end up being nuclear, parents plus two children or less.

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 centres 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.

Malnutrition

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.

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% and lead to a potential reduction in lifetime earnings for each malnourished individual.

Stunting among children is linked to a 4.6 cm 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.

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.

However, under nutrition, 29% underweight is high. This is the measure of non income face of poverty, the 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.

In India it is estimated that nearly half of the small children are malnourished, this is higher than in most parts of sub-Saharan Africa. More than one third of the world’s malnourished under-fives live in India.

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.

Double jeopardy

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 the 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 that 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!

Small window of opportunity

Under nutrition in Sri Lanka affects very young children and mothers, often during pregnancy, leading to low birth weight. Early damage caused to children’s cognitive and growth potential 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 mothers and until the newborn is 18 to 24 months old, the critical 1,000 days from conception to the child’s second birthday.

Recent research shows that a large part of the damage is caused to the foetus while in the womb, before birth. What has to be done is known, it is not rocket science. The pregnant mother-to-be must be given supplements of multiple micronutrients, 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.

Proven model for delivery

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 Janasaviya 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 the 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 and cleaners, it is a bureaucratic nightmare for DMOs. Some remote areas hardly get deliveries. Mothers turn up for the clinic and go away frustrated.

The system punishes 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!

Important 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. It is estimated that 3.5% of the brain is developed 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 programme 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 programme 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 base line 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 predetermined 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 programme was participatory with bottom-up planning and sequenced, realistically achievable stage by achievable stage.

Successful intervention

The Implementation Completion Report of the World Bank, on Sri Lanka’s Poverty Alleviation Project, implemented by the 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 three-fourths of the sites at which the Nutrition programme 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 newspapers, radio and TVs. The grandmother, mother and girl child should be targeted by an aggressive outreach programme if this cycle of under nutrition, malnutrition and irreversible damage to children’s cognitive and growth potential is to be broken.

Addressing malnutrition

Sri Lanka’s current problems on child and maternal malnutrition are further compounded by fact that a healthcare system, human resources plan, infrastructure and budget, which has evolved to respond to health hazards caused by communicable diseases in a young population, diarrhoea, malaria and filarial, etc., is today, struggling to treat a rapidly ageing population suffering from non-communicable diseases and other geriatric illnesses, like high blood pressure, cancers and diabetes, etc.

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.

Addressing malnutrition in Sri Lanka will require strategies to reduce income inequalities, improve access to safe water and sanitation, reduce food insecurity, scale up direct nutrition interventions, use the successful participatory delivery mechanism well proven in the Janasaviya Trust Fund’s Nutrition Intervention and revise and reform the Government health expenditure and infrastructure to reflect the preventive and curative health demand realities of today. For the malnutrition conundrum, there is a well-proven delivery system for the necessary interventions.

Today’s child will inherit tomorrow’s Sri Lanka. We have to ensure that are inheritors are not stunted and intellectually challenged; for if they are, in today’s globalised competitive world, they will simply not be successful.



(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.)