Nutrition in emergencies
Eighteen-month-old Owais is too young to register the devastation of the violent earthquake that struck areas near the Pakistan-India border on 8 October 2005, or to have any memories of the events that followed. But, as he grows up an orphan, he will come to realize that the earthquake changed his life forever.
Owais lost both his parents and is now cared for by his 70-year-old grandfather, Abdur Rahman. “Now that Owais’ parents are gone, I find myself alone rearing the baby until he becomes a young man,” he said, desperately trying to conceal his tears. “I do not know if I will live that long.”
He described how for about 10 days following the quake Owais refused to accept bottle feeding, as he had been used to being breastfed, adding “with passing time however, he’s accepting the bottle and now he doesn’t cry so much anymore.”
Owais is one of thousands of children affected by the earthquake. Their stories have been broadcast around the world, eliciting generous donations which in turn translated into supplies, shelter, aid workers and much-needed health interventions.
Meanwhile, in other parts of the world, the daily deaths of thousands of children go unnoticed. About 5.6 million children under five die each year from causes linked to undernutrition. Their suffering is not the result of an emergency situation but of an ongoing crisis occurring away from the public eye. Their vulnerability is often exacerbated by chronic poverty, erratic economies, poor infrastructure and the effects of HIV/AIDS.
In southern Africa, HIV/AIDS is contributing to a vicious downward spiral where poverty and undernutrition reduce disease defences, possibly affecting susceptibility to and vulnerability from HIV infection. With each downward spiral, households and communities are becoming destitute. Coping practices and resources that once allowed communities to survive through isolated periods of hardship are diminished, leaving communities more vulnerable to future shocks 1.
Ironically, children affected by major emergencies have a better chance of survival than their counterparts in countries less affected by such dramatic events. This is the result of public attention gravitating towards conflict and natural disasters, coupled with increasingly effective humanitarian relief interventions.
Indeed, the international community has become much more adept at saving the lives of children who are dangerously thin (or wasted) in the context of catastrophes than those of children suffering from undernutrition in the context of the poverty and underdevelopment that is routine in their lives.
Undernutrition has persisted in Pakistan for decades, and improvement has been slow in coming. The nutrition situation was expected to further deteriorate after the October 2005 earthquake, yet a survey conducted just 6 to 12 weeks after indicated that designating the situation a nutrition crisis was not warranted 2.
This was most likely due to rapid food assistance and access to health-care services provided by the government, international agencies, NGOs and communities. Despite the high mortality rate resulting from the earthquake, immediate and effective treatment of injuries and infections prevented additional sickness and death.
And yet, if ongoing crisis situations affecting children’s nutritional status are not dealt with, they might become a springboard for a sudden leap in mortality when an emergency does occur. This has happened in Niger, where there had been an ongoing ‘silent emergency’. The country has the third highest under-five mortality rate in the world and thousands of children are underweight.
A survey conducted amid the devastating nutrition crisis in 2005 found that wasting rates in children aged six months to three years old was about four times higher than for three-to-five-year-olds. Moreover, 70 per cent of wasted children in the younger age group were also stunted 3.
International relief efforts during acute emergencies are undoubtedly effective in preventing loss of life linked to undernutrition. Yet if the number of deaths related to undernutrition is to be reduced, global attention will have to also increasingly focus on those relatively stable developing countries where the nutritional status of children is most at risk – and where most children under five die each year.
1 UNICEF, ‘Drought, HIV/AIDS and Child Malnutrition in Southern Africa: Part 1 – Preliminary analysis of nutritional data on the humanitarian crisis’, United Nations Children’s Fund, Regional Office for Eastern and Southern Africa, Nairobi, 2003, p. 9.
Stunting is a key indicator for poverty
Stunting, or growth retardation of children, is well established as an indicator of undernutrition. It is also an appropriate indicator for child poverty, since it reflects economic and social deprivation and whether children’s basic needs have been adequately met in their early years 1.
An estimated 168 million children under five in the developing world are stunted or too short for their age, a consequence of not getting enough food, of living in an unhealthy environment, and of a lack of health care, attention and stimulation in early childhood.
Like two other indicators of child undernutrition, underweight (children whose weight is too low for their age) and wasting (children who are too thin), stunting is relatively easy to measure. However, unlike underweight and wasting – both remedied through timely and appropriate interventions such as provision of food or therapeutic feeding – the effects of stunting are largely irreversible.
And the effects are not confined to vertical measurements: they are long term and intergenerational. Stunting begins during pregnancy, results in life-long damage and may be passed onto the next generation.
Women who are stunted are more likely to have obstructed labour and are at a greater risk of dying during childbirth 2. They are more likely to deliver low-birthweight and stunted children who have lower levels of educational attainment, reduced physical capacity, and poor resistance to infection and disease. In adulthood, stunting translates into diminished work capacity and a higher propensity to diseases such as diabetes, heart disease and hypertension 3.
Stunting is correlated with levels of income, and low-income countries generally have higher rates of stunting. In the least developed countries, for instance, 42 per cent of children under five are stunted, compared to the global figure of 30 per cent of children under five. In Latin America and the Caribbean, a study done in four Andean countries found a high level of stunting related to a low socioeconomic status. Those in the poorest sectors of these countries were at least three times as likely to be stunted as those in the richest 4.
As with other indicators of undernutrition, stunting is most prevalent in South Asia, particularly in Afghanistan and Nepal, where more than half of under-fives are affected. In CEE/CIS, Albania and four Central Asian countries have the highest rates of stunting, far surpassing the regional average of 14 per cent. Two of the four Central Asian countries have the lowest regional levels of gross national income per capita 5.
Eliminating the underlying causes of stunting will help break the cycle of poverty. A holistic approach starts with improving the nutritional status of adolescent girls and women to ensure that once they become pregnant they give birth to healthy children. It entails strengthening support for exclusive breastfeeding – starting right after birth and followed six months later by sufficient, high-quality and safe complementary feeding – and ensuring an adequate, safe water supply and proper sanitation for mothers and their children.
Breaking the cycle will also require scaled-up micronutrient fortification programmes, so that children and women receive the vitamins and minerals essential for healthy growth and development, and equitable access to good health care – including medicines and vaccines – so that children are protected from disease. All these elements will have the highest impact if, in addition, children receive the necessary stimulation, care and love.
For children to grow properly, their basic needs must be satisfied. However, this will require national policies, budgets and programmes to focus sufficiently on meeting the needs and rights of the poor. Many countries will need support from the international community, since on their own they will not be able to achieve coverage of basic social services for all.
1 Gross, Rainer, ‘Nutrition and Alleviation of Absolute Poverty in Communities: Concept and measurement’, ACC/SCN Symposium Report, Nutrition Paper 16, 1997, pp. 95-103.
School feeding alleviates hunger and gives education a boost
In many parts of the world, children arrive at school with empty bellies. They may miss their morning meal, not get enough or the right things to eat, or be required to participate in family labour before school. As a result, they come to school with little energy to concentrate, engage with their teachers and classmates, or participate in physical education and other practical learning situations. These hungry children are more prone to low performance, to be absent from school, to fall sick and to drop out.
The lack of proper nutrition is one reason why an estimated 115 million school-aged children around the globe are out of primary school 1. Many of these children may also suffer from micronutrient deficiencies, the lack of essential vitamins and minerals. This ‘hidden hunger’ affects brain development and compromises the immune system.
School feeding programmes offer the opportunity to alleviate hunger – both overt and hidden – among children. But their benefits go beyond nutrition. Studies have found that school feeding programmes provide an incentive for parents to send their children for an education, encourage children to stay in school and help them to focus and retain what they learn.
In the poorest pockets of the world, this strategy has been shown to double primary school enrolment in just one year 2. It costs just pennies. The World Food Programme estimates that on average, a child can be fed in school for about US 19 cents per day, or US$34 annually.
UNICEF works in partnership with the World Food Programme to provide an integrated package of cost-effective interventions to improve the nutritional status and health of schoolchildren. Food for Education, an essential component of this package, seeks to alleviate short-term hunger in schoolchildren, increase parents’ motivation and enhance community participation in schools 3.
A multiplicity of benefits
In impoverished parts of Bangladesh, some 1 million children receive a mid-morning snack of biscuits that provide energy and much of the daily requirement of vitamins and minerals. In about one year, the programme raised net primary school enrolment by almost 10 per cent, and reduced the probability of dropping out by 7.5 per cent 4.
After receiving breakfast in school, children in rural Jamaica were more attentive and less fidgety in class and their verbal fluency improved. The most positive effects were seen in adequate sized classrooms that were quiet, airy and well lit 5.
In countries where take-home ration programmes have been implemented, girls’ primary school enrolment increased by at least 50 per cent 6.
School feeding programmes can provide a launching pad for health programmes in schools, and HIV prevention and deworming are recognized interventions. They also provide an excellent opportunity for targeted micronutrient supplementation among schoolchildren, and the nutritional content of meals or snacks can be adjusted to optimize absorption of iron, vitamin A and other essential nutrients.
A recent UN Girls’ Education Initiative (UNGEI) technical meeting recommended school feeding programmes as part of an essential learning package to accelerate quality education for all. The recommended package also includes intervention areas such as water and sanitation, deworming and micronutrient supplementation 7.
1 UNICEF, Progress for Children No.2 – A report card on gender parity and primary education, UNICEF, New York, April 2005, p. 3