We all share in the cost of lower education, reduced labor productivity, and escalating health care costs.
End of Hunger
This essay appears in the book The End of Hunger edited by Jenny Eaton Dyer and Cathleen Falsani. The book features essays from others such as Rick Bayless, Jeffery Sachs, and Kimberley Williams-Paisley and Brad Paisley.
A young mother, only twenty-two years old, sat on the edge of a hospital bed, her six-week-old daughter swaddled tightly to her chest. Mother and daughter had been inseparable, bound by this skin-to-skin contact since the birth, when the baby weighed just nine hundred grams, or slightly less than two pounds. She constantly needed her mom’s warmth and milk.
“I’m Gita,” the mother announced to a group of visitors. Her daughter didn’t have a name yet—Gita said she wanted to wait until she knew her baby would survive. She was playing a board game, Snakes and Ladders, with another mother who also cradled a low birth weight child. Gita was in high spirits. “I’ve won three out of four games,” she said.
But there was a greater reason for her joy. Her daughter had been weighed again that morning, and the news was encouraging. “She is 1,730 grams now,” Gita proclaimed with great pride.
The baby’s birth weight had nearly doubled. Another three hundred grams and mom could think about taking her daughter home—and finally giving her a name.
In India’s maternity wards, the scales tell the story of the country’s— and the world’s—battle against malnutrition. Malnutrition remains a leading cause globally of nearly half of all deaths of children under the age of five.
In India, more than one-fifth of all babies come into the world with a low birth weight (less than five-and-a-half pounds by international standards). As infants, 21 percent suffer from wasting, or severe underweight according to height. By the time they reach five years of age, nearly 40 percent are stunted either physically, cognitively, or both.
Much of this is due to diets lacking the vital vitamins and nutrients that fuel healthy and strong growth and development. India is home to more than one-third of the world’s malnourished children, and a quarter of the world’s newborn deaths.
Anemia plagues more than half of Indian women of reproductive age, and nearly 60 percent of all children under age five. Nearly one quarter of women have a low body mass index. Aggravating the malnutrition are widespread poor sanitation and hygiene, which lead to parasites and water-borne diseases that rob a person’s body of whatever nutrients they may consume.
Gita, who comes from an impoverished rural area in the state of Uttar Pradesh, was malnourished and anemic when she was pregnant, and she gave birth a month prematurely. She and her daughter were rushed to the capital city of Lucknow and its District Women’s Hospital. A large sign hanging in the hallway of its maternity ward heralds a new treatment the hospital is pioneering: “KMC Unit,” shorthand for Kangaroo Mother Care, so named because swaddled newborns resemble joeys (baby kangaroos) in their mothers’ pouches. Such skin-to-skin swaddling immediately after birth is more conducive for breastfeeding, helping to encourage weight gain and to prevent hypothermia.
While they nurse their babies under the watchful eye of a team of nurses and doctors, at the District Women’s Hospital new mothers eat a steady diet of nutritious vegetables and fruits—bananas, apples, mangos, whatever is in season—so they can gain strength and also pass the nutrients on to their babies through their breast milk. Even though India is the world’s second largest producer of fruits and vegetables, many families cannot afford them, creating the paradox of so much malnutrition amid such abundance.
In the past, the odds would have been slim that Gita’s baby would survive, but the new mother was encouraged by the statistics she learned from the nurses: 936 severely underweight babies were treated in the KMC ward, and 850 had survived since it opened twenty months earlier in 2016. The KMC treatment is now a centerpiece of the Indian government’s National Nutrition Mission, which aims to end the tragic and costly consequences of hunger and malnutrition.
A particular focus of the new nutrition strategy is given to the first one thousand days of life—the time from when a mother first becomes pregnant to the second birthday of her child. This is the most important time for individual human development, when the foundation for good physical growth is laid, when the brain is growing most rapidly and expansively, and when the immune system strengthens for a life of good health. It is the time that determines a child’s ability to learn in school, perform at a future job, and ward off chronic disease as an adult.
Good nutrition is essential to fuel all of that growth. Any prolonged bout of malnutrition in the first one thousand days leads to stunting, both physical and cognitive. While the clinical definition of stunting is being too short for one’s age, in reality, by the time a child reaches the age of two, stunting usually means a life sentence of underachievement.
Today, globally, one in four children under the age of six is stunted— imagine the lost opportunities—which is why the first one thousand days of a child’s life also are the most important for the healthy development of families, communities, nations, and the world as a whole.
In reporting for my book The First 1,000 Days: A Crucial Time for Mothers and Children—And the World, I followed moms and their children in India, Uganda, Guatemala, and Chicago on their one-thousand-day journeys.
I expected to find many differences between the mothers and children in the varied locations, but was surprised to discover just as many commonalities, chief among them the hope for every child who comes into the world to achieve all that is possible. It is the most widely shared human aspiration. And when it doesn’t happen, we all bear the burden.
A stunted child anywhere in our world becomes a stunted child everywhere. We all share in the cost of lower education, reduced labor productivity, and escalating health care costs. The impact of a stunted child rolls through time and across societies and around the world like the ripples that spread from a single pebble cast into a still pond.
It begins with an individual boy or girl. A child with stunted cognitive development has difficulty learning in school and drops out early, which diminishes the child’s prospect for success in the labor force. A study in eastern Guatemala that now spans a half-century has found that children who were well nourished in their first one thousand days completed a couple more grades of school than malnourished children. As adults, the better-nourished group earned 20 to 40 percent more in wages, and were less likely to develop a chronic illness.
Next, the impact spreads to the stunted child’s family members, who are likely to earn less than a full wage and incur higher health care costs, in turn making it more difficult for any of them to climb out of poverty.
For many families, the effects of malnutrition and stunting steamroll through the generations in an accumulation of historical insults: stunted girls grow up to be stunted women who give birth to underweight babies who themselves are stunted. And the vicious cycle grinds on.
The ripples from stunting then engulf the community at large, for where there is one malnourished child, there certainly are more. Labor pools are depleted, productivity is sapped, and economic growth lags.
The exponential reach of stunting then continues to radiate outward, crippling entire countries and even continents. Nations with high childhood stunting rates calculate that they annually lose between 5 percent and 16 percent of their gross domestic product to low labor productivity, high health care expenditures, and other effects of malnutrition. Sub-Saharan Africa and South Asia—where aggregate malnutrition stands at about 40 percent and stunting rates are the highest in the world—each lose an estimated 11 percent of their economic activity every year.
Why do some countries and regions of the world remain poor? Because their mothers and children are malnourished and stunted. Because they have a lousy first one thousand days.
Which brings us to stunting’s final, devastating ripple effect. According to the World Bank, the cumulative toll of the individual, family, community, and national costs imposes a significant drag on global productivity, international trade, and health care, stunting the world economy by about $3 trillion a year.
While that is a massive number, perhaps the greatest costs of malnutrition and stunting remain immeasurable.
A poem never written.
A song never sung.
A story never told.
A technology never invented.
A building never designed.
A mystery never solved.
A horizon never explored.
An idea never formed.
An inspiration never shared.
An innovation never nurtured.
A cure never discovered.
Imagine what a child might have achieved for all of humankind were she not stunted?
It's a thought that haunts Dr. Vishwajeet Kumar, an Indian physician who studied and worked in the United States before returning home to tackle the problem of infant mortality in a rural area of the state of Uttar Pradesh.
In Uttar Pradesh, among the poorest regions in India, nearly 55 percent of children younger than three years old were stunted, 42 percent were underweight, and 85 percent suffered from some level of anemia—and those were the children who survived the first months of life.
The newborn mortality rate in the area where Vishwajeet set up his practice was exceedingly high—more than eighty out of every thousand live births. The residents largely believed such infant deaths were fated. But Vishwajeet insisted they were preventable.
Your babies didn't have to die, he told the mothers. You have the power to ensure they will live. Vishwajeet's challenge was to move the women and their communities from a state of fatalism to a state of control. To do this, he forged an alliance between modern medicine, community beliefs, and government.
As he began his work, Vishwajeet likened himself to an amateur diver, exploring a new world of strange phenomena. What he discovered in the villages were traditional practices and superstitions, deeply rooted in the region's caste system, culture, and spirituality, that were having a profound impact in the one thousand days. Folk wisdom and common custom encouraged families to make choices discordant with all he had learned in medical school.
More than 80 percent of women still were insisting on delivering their babies at home, even with the proliferation of clinics and hospitals in the countryside. The newborns would be taken from their mothers and thoroughly washed—sometimes heavily scrubbed, even cleansed with mud from a pond—and then left on their own, unclothed, lying on the ground for up to an hour, while the home birth attendants turned to caring for the mothers, as the risk to her life after giving birth was perceived to be higher. This washing and scrubbing was a ritual meant to cleanse away evil spirits, but it dangerously exposed the babies to deadly hypothermia and infection.
Breastfeeding didn't begin for several hours, at the earliest, or in some instances several days; less than 20 percent of newborns in Shivgarh were breastfed immediately. Instead, the first breast milk, containing the antibody-rich colostrum, was discarded because it was considered part of the afterbirth and therefore "unclean." The first liquids a baby received would be cow's milk, water (unpurified, straight from the well), or a drop of honey.
Vishwajeet's team of medical scientists worked with local community leaders to identify a common objective: improve infant survival. Next, they aligned the traditional belief that evil spirits (known as jamoga) harm newborns, with the scientific, medical knowledge that infections cause harm to newborns. Infections were jamoga too, Vishwajeet explained, and with this patients began referring to infections as "germoga."
Together, Vishwajeet and community leaders designed a package of behavioral changes—hygienic delivery, light cleansing of the newborn instead of the traditional thorough scrubbing, skin-to-skin contact between mother and child, and immediate breastfeeding with the colostrum— that could conquer the evils (by any name) that contributed to infant deaths.
Vishwajeet named his budding organization the Community Empowerment Lab. But in homes up and down dusty village streets, the women called it, simply, Saksham (meaning "empowerment").
When working with the communities, Vishwajeet's favorite visual aid was a mother's own hand with her fingers spread wide. "There are five secrets to success," he would tell the women, assigning one secret to each finger. "One, love. Two, warmth. Three, food—breast milk. Four, hygiene. Five, care—know the signs when your baby is sick and go to the doctor. These behaviors are all in your control. They are in your hands."
It was a revolutionary concept—empowering mothers—in a country where women often have little say in their own homes, even when it comes to reproductive and family planning decisions. And yet, the plan worked.
Within sixteen months, neonatal mortality in the Saksham villages was cut in half—forty-one deaths per one thousand live births, compared to eighty-four in neighboring villages where the changes hadn't yet been introduced. Maternal deaths during childbirth became ever rarer. Local government followed Saksham’s lead and incorporated the basic tenets of care for pregnant women and their newborn children into the state's public programs, including the Kangaroo Mother Care units.
The Indian government, through its National Nutrition Mission, has set ambitious goals for the next three years: reduce stunting, undernutrition, and low birth weight by six percent; lower the prevalence of anemia among young children and women of child-bearing years by nine percent; and reduce stunting among children under the age of six from the 2016 level of 38.4 percent to 25 percent.
India has made steady progress since 2005, when its stunting rate hovered at nearly 50 percent. But has it come too late for the children on the KMC ward? The odds that they will survive are improving, but will they thrive? Or has stunting already given them a life sentence of underachievement?
The answers to those questions will determine not just India's future, but our own. For a single child to lose a chance at greatness is a loss for all of us.
"I Am Gita" by Roger Thurow, from The End of Hunger, edited by Jenny Eaton Dyer and Cathleen Falsani. Copyright (c) 2019 by The Eleanor Crook Foundation. Used by permission of InterVarsity Press, P.O. Box 1400, Downers Grove, IL 60515-1426. www.ivpress.com.
Some of the material in this chapter was adapted from Roger Thurow, The First 1,000 Days: A Crucial Time for Mothers and Children—and the World (New York: PublicAffairs, 2016).