The silent emergency
Malnutrition is implicated in more than half of all child deaths worldwide a proportion unmatched by any infectious disease since the Black Death. Yet it is not an infectious disease. Millions of its survivors are left crippled, vulnerable to illness and intellectually disabled. It imperils women, families and, ultimately, the viability of whole societies, and is a violation of children's rights. Long recognized as a consequence of poverty, malnutrition is increasingly viewed as a cause. Yet the worldwide crisis of malnutrition has stirred little public alarm.
Malnutrition is not a simple matter of whether a child can satisfy her or his appetite. A child who eats enough to satisfy immediate hunger can still be malnourished. And malnutrition is largely an invisible emergency. Three quarters of the children who die worldwide of malnutrition-related causes are mildly to moderately malnourished and betray no outward signs of problems.
Famines, wars and other catastrophes are responsible for only a tiny part of the worldwide malnutrition crisis. But such emergencies, like the ongoing crises in the Great Lakes region of Central Africa and in the Democratic People's Republic of Korea, often result in the severest forms of malnutrition.
Child malnutrition is not confined to the developing world. In some industrialized countries, widening income disparities, coupled with reductions in social protection, are having worrying effects on the nutritional well-being of children.
In some parts of the world notably Latin America and East Asia there have been dramatic gains in reducing child malnutrition. But overall, the absolute number of malnourished children worldwide has grown. Half of South Asia's children are malnourished. In Africa, one of every three children is underweight, and in several countries on the continent, the nutritional status of children is worsening.
Malnutrition can take a variety of forms that contribute to each other, such as protein-energy malnutrition and deficiencies of micronutrients such as iodine, iron and vitamin A, called micronutrients because they are needed in such tiny amounts. At its most basic level, malnutrition is a consequence of disease and inadequate dietary intake, but many more elements are involved. Discrimination and violence against women are major causes of malnutrition, for example.
There is, in short, nothing simple about malnutrition except perhaps the fact of how vast a toll it is taking.
Of the nearly 12 million children under five who die each year in developing countries mainly from preventable causes, the deaths of over 6 million, or 55 per cent, are either directly or indirectly attributable to malnutrition. Anaemia is a contributing factor in 20 to 23 per cent of all post-partum maternal deaths in Africa and Asia.
Anaemia in infancy and early childhood can delay psychomotor development and impair cognitive development, lowering IQ by about 9 points. Low-birthweight babies have IQs that average 5 points below those of children with birthweights in the normal range. Severe iodine deficiency in utero can cause the profound mental retardation of cretinism, but milder deficiencies also take an intellectual toll. In the republic of Georgia, for instance, a widespread iodine deficiency is estimated to have robbed the country of 500,000 IQ points in the 50,000 babies born in 1996 alone. The depletion of human intelligence on such a scale is a profligate, even criminal, waste.
Vitamin A deficiency, which affects about 100 million young children worldwide, was long known to cause blindness. But it has become increasingly clear that even mild vitamin A deficiency also impairs the immune system, reducing children's resistance to diarrhoea, which kills 2.2 million children a year, and measles, which kills nearly 1 million annually.
In 1990 alone, the worldwide loss of social productivity caused by just four overlapping types of malnutrition nutritional stunting and wasting, iodine deficiency disorders and deficiencies of iron and vitamin A amounted to almost 46 million years of productive, disability-free life, according to one reckoning.
Vitamin and mineral deficiencies are estimated to cost some countries the equivalent of more than 5 per cent of their gross national product (GNP) in lost lives, disability and productivity. By this calculation, Bangladesh and India forfeited a total of $18 billion in 1995.
Many children suffer from multiple types of malnutrition, so numbers tend to overlap. But it is estimated that 226 million children are stunted, shorter than they should be for their age. A study in Guatemala found that severely stunted men had, on average, 1.8 fewer years of schooling than those who were non-stunted, while severely stunted women had, on average, one year less. Every additional year of schooling translated into 6 per cent more in wages.
Nearly 67 million children are estimated to be wasted, which means they are below the weight they should be for their height. And about 183 million children weigh less than they should for their age. In one study, children who were severely underweight were found to be two to eight times more likely to die within the following year as children of normal weight for their age.
More than 2 billion people principally women and children are iron deficient, and the World Health Organization (WHO) has estimated that 51 per cent of children under the age of four in developing countries are anaemic.
In the United States, researchers estimate that more than 13 million children have a difficult time getting all the food they need. In the United Kingdom, children and adults in poor families face health risks linked to diet, according to a recent study that cited high rates of anaemia in both children and adults, and of premature and low-weight births, dental diseases, diabetes, obesity and hypertension.
In Central and Eastern Europe, economic dislocations accompanying the transition to market economies and major cutbacks in state-run social programmes are having a more profound effect on the most vulnerable. In the Russian Federation, for example, the prevalence of stunting among children under two years of age increased from 9 per cent in 1992 to 15 per cent in 1994.
The infants of women who are themselves malnourished and underweight are likely to be small at birth. Overall, 60 per cent of women of childbearing age in South Asia are underweight. In South-East Asia, the proportion of underweight women is 45 per cent; it is 20 per cent in sub-Saharan Africa.
The power of good nutrition
The devastation of malnutrition is hard to overstate, but so is the countervailing power of nutrition. The most obvious proof of the power of good nutrition can be seen in the taller, stronger, healthier children of many countries, separated by only a generation from their shorter, less robust parents. Each year 12 million children are now being spared irreversible mental impairment from iodine deficiency because of iodized salt. And more than 60 per cent of young children around the world are receiving vitamin A supplements.
History shows that societies that meet women's and children's nutritional needs also lift their capacities for greater social and economic progress. Approximately half of the economic growth achieved by the United Kingdom and a number of Western European countries between 1790 and 1980, for example, has been attributed to better nutrition and improved health and sanitation conditions, social investments made as much as a century earlier.
Even in countries where poverty is entrenched, nutrition can be protected. In parts of Brazil, for example, the percentage of underweight children plummeted from 17 per cent in 1973 to just under 6 per cent in 1996, at a time when poverty rates almost doubled.
The right to good nutrition
However far-reaching the benefits of nutrition may be, ensuring good nutrition is a matter of international law, articulated in international declarations and human rights instruments dating back to the adoption of the Declaration of the Rights of the Child in 1924. Under the 1979 Convention on the Elimination of All Forms of Discrimination against Women, for example, States parties must ensure that women receive full and equal access to health care.
But the right to nutrition receives its fullest expression in the 1989 Convention on the Rights of the Child, ratified by 191 countries as of late 1997 and the most universally embraced human rights instrument in history. Under the Convention, virtually every government in the world recognizes the right of all children to the highest attainable standard of health, including the right to good nutrition and its three vital components: food, health and care.
And under the Convention's pre-eminent principle, good child nutrition is a right because it is in the "best interests of the child."
Article 24 of the Convention specifies that States parties must take "appropriate measures" to reduce infant and child mortality, and to combat disease and malnutrition through the use of readily available technology and through the provision of adequate, nutritious foods and safe drinking water.
Why time is of the essence
A child's organs and tissues, blood, brain and bones are formed, and physical potential is shaped, during the period from conception through age three.
Since human development proceeds rapidly for the first 18 months of life, the nutritional status of pregnant and breastfeeding mothers and young children is of paramount importance for a child's later development.
The healthy newborn develops from a single cell roughly the size of the period at the end of this sentence and has some 2 billion cells and weighs an average of 3,250 grams. Under optimal conditions, birthweight will double in the first four months of life; by the third birthday, a healthy child will be four and a half times as heavy.
Growth during the foetal stage depends on how well nourished a woman was before pregnancy, as well as how much weight she gains while she is pregnant. But fulfilling these interlocking food, health and care needs can be a struggle for many women in the developing world. Currently about 24 million low-birthweight babies are born every year, about 17 per cent of all live births, mainly in developing countries. Low-birthweight babies, defined as weighing less than 2.5 kilograms, are at greater risk of dying than infants of average weight. If they survive, they will have more episodes of illness, their cognitive development may be impaired and they are also more likely to become malnourished.
Measures that are essential for an expectant mother care and rest, a reduced workload and a nutritious diet are equally important when a woman is breastfeeding her child.
Breastfeeding perfectly combines the three fundamentals of sound nutrition food, health and care. In countries where infant mortality rates are high or moderately high, a bottle-fed baby in a poor community is 14 times more likely to die from diarrhoeal diseases and 4 times more likely to die from pneumonia than a baby that is exclusively breastfed. In one study, children who were breastfed generally had IQs about 8 points higher than children who were bottle-fed.
However, for mothers infected with HIV, breastfeeding's enormous value must be weighed against the 14 per cent risk that they may transmit the virus to their infants through breastmilk and the vastly greater risk, especially in poor communities with inadequate water and sanitation, that feeding their children artificially will lead to infant deaths from diarrhoeal dehydration and respiratory infections.
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