Abstract
W
As I first arrived in the village of Rampur Khas, in the Indian state of Uttar Pradesh, a gathering of two dozen new moms and moms-to-be were sitting on the floor of a veranda. It was a communal education class on best nutrition and hygiene practices in the first 1,000 days period, from the time a woman becomes pregnant to the second birthday of her child.
The moms had put the lessons to song, the better to remember and spread the word among illiterate and poorly educated women.
To the beat of a homemade drum, they sang:
They continued with a second verse:
These lyrics were an essential element of an effort to reduce the astronomically high number of infant deaths. In this area of India, the infant mortality rate was upwards of 80 deaths per 1,000 live births. Many of those children were dying on their first day of life because of infection, compromised immune systems, and hypothermia.
Village health workers connected with a local organization called the Community Empowerment Lab found that changing behaviors tied to old customs and traditions were key to eliminating infant deaths. A top target was the common practice of discarding the first breast milk, along with the antibodies-rich colostrum, because it was seen as dirty, impure, part of the afterbirth. The song hailed the benefits of breastfeeding immediately after birth.
As the lyrics, and the communal education, spread from village to village, and as the moms put the lessons into practice, the number of infant deaths began falling. Within 16 months, the neonatal mortality rate had been cut in half.
At the public hospital where they would deliver, the maternity ward is a dark and gloomy place. And woefully overcrowded. There are only four metal beds with thin mattresses and washed-out sheets in the tiny room where moms wait before giving birth and to where they return afterward. It is a dingy space with dirty walls and drab curtains.
The only splash of color in the room is on the far wall above one of the beds. It is a poster from PATH and India's Rural Health Ministry. It features a beaming mom snuggling her baby, and this bold, empowering message in Hindi:
“In the First Hour, a mother can change the fate of her child.”
Four simple drawings at the bottom of the poster illustrate how:
▪ Make sure a clean blade is used to cut the umbilical cord to prevent infection. ▪ Practice Kangaroo Mother Care; placing the newborn on the mother's chest provides warmth and avoids hypothermia. ▪ Breastfeed immediately. ▪ Alert a medical professional if the child appears ill.
The moms of Rampur Khas recognized these practices from their meetings with the Community Empowerment Lab. It was founded by an Indian doctor who had been studying and working at Johns Hopkins in Baltimore. His goal initially was to reduce first-day and infant deaths. The community workers, focusing on behavior change practices, had pregnant mothers hold up their hands with fingers spread wide. “There are five secrets to success,” they would say, and point 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.”
But as the moms would learn, many things conspire to remove these aspects, including breastfeeding, from a mother's hands. There are the barriers of social and cultural traditions, shortages of healthcare workers, a deficit of breastfeeding knowledge, lack of maternity legislation, and the marketing of breast milk formula substitutes.
I saw these barriers in each country:
For the moms in Uttar Pradesh and elsewhere in India, tradition and custom demanded that they discard the first milk. Moms in other places were required by custom to withhold breastfeeding until the local spiritual leader came and blessed the child. That could be a matter of minutes, or it could be days.
In Uganda, traditions varied from community to community, with some insisting that a mother give her baby a sip of sugar-sweetened water or animal milk, a dollop of honey, a drop of home-brewed beer, or moonshine. Those are all very bad for a baby, of course.
In Guatemala, there was generally good support for breastfeeding in the hospitals. In the maternity ward of the main public hospital in the city of Quetzaltenango in the western highlands, a large pot was filled with tea laced with a local herb that was said to help produce breast milk. I noticed that there was always a line of new moms waiting to fill a cup with that elixir. But I would come to learn that in many homes, there was often a lack of support. Several of the moms I was following through the 1,000 days worried that their baby was not getting enough of her milk, so in despair they reached for the bottle and formula. And for the illiterate moms, they did not understand the mixing instructions, so they often did not add enough formula, and their babies suffered mightily.
In Chicago, one of the moms—a teenager—fell asleep after long, strenuous labor. When she woke, she wanted to breastfeed. She pushed a bedside buzzer for assistance, but no one came. She pushed the buzzer again; no response. She looked at the tray beside the bed and noticed a bottle with water and a little packet of infant formula powder. She pushed the buzzer again. Frustrated, she reached for the bottle and mixed the formula. The baby took to the bottle. The mother later learned that her daughter had been bottle fed by a nurse while she slept. And now, it seemed, her baby preferred it. That hospital had the lowest newborn breastfeeding rate in the city, just 10%.
Contrary to the poster in the Indian maternity ward, many forces loom that can dislodge the breastfeeding decision from the hands of a new mother.
Breastfeeding, of course, is a critical step in setting up a child for success later in life. It is a crucial part of the good nutrition that is so vital in the first 1,000 days.
For what happens in these early days determines to a large extent the course of a child's life—his or her ability to grow, learn, work, succeed—and, by extension, the long-term health stability and prosperity of the society in which that child lives.
It is in these 1,000 days when stunting—cognitively or physically, or both—begins. In the second decade of the 21st century, one in every four children under the age of 5 years in the world is stunted—about 170 million children in total. That is astonishing, staggering.
A child who is severely stunted is sentenced to a life of underachievement: diminished performance in school, lower productivity and wages in the workplace, more health problems throughout life, and a greater propensity for chronic illnesses such as diabetes and heart disease as an adult.
And that life sentence is most often rendered by the time a child is 2 years. For stunting is largely the result of a debilitating mix of poor nutrition, unclean environments, and lack of caregiver stimulation during the 1,000 days.
What's wrong with us? One in four children stunted? Why do we continue to squander so much potential?
We know what is important. Good nutrition is the indispensable fuel of growth and development, particularly in the 1,000 days. It is the accelerant of a good start in life.
Babies growing in the womb receive all nutrients from their mother. If she lacks key vitamins and minerals in her diet for her own health, so will her baby.
For infants, mom's breast milk provides an array of vital micronutrients and an early immunization against illness and disease that helps fortify the body for life.
Once complementary feeding begins, healthy foods ensure continued growth and brain development.
Any prolonged shortage of food or persistent lack of vital micronutrients in the 1,000 days can set back growth and development, sometimes irreversibly. So, too, can repeated bouts of diarrhea that take nutrients out of the body, or an intestinal infection of worms or parasites that prevent the body from absorbing the minerals and vitamins it needs—making clean water, proper hygiene, adequate sanitation, and access to basic healthcare vital accompaniments to good nutrition.
We know all this. And yet, the ancient scourge of malnutrition—this medieval suffering—persists as our planet's most pressing threat to health and prosperity.
The 1,000 days is not new. It is a period that has always existed, of course. But it has never been the center of attention in public health policy.
In the past, the development community has usually fixated on age 5 years and primary school as milestone targets for intervention. Getting children into school—universal primary education—has long been a holy grail of successful development, whereas ensuring proper brain growth and cognitive development in the first 1,000 days, so children are actually capable of learning once they get there, has largely been neglected.
In the United States, national dietary guidelines have been directed to children of age 2 years and up, with a particular focus on school-age children. Interventions to prevent undernutrition, such as school feeding programs, and initiatives to lower obesity rates have also centered on primary school rather than on the 1,000 days, when the consequences of malnutrition are most severe and the preconditions for obesity are forming.
And nutrition has long been the neglected stepchild of international development—part agriculture, part health, but disdainfully disowned by both.
In past decades, less than 1% of total international development aid has been spent on nutrition. It was an illogical imbalance: nutrition was everywhere in human development, but virtually nowhere in development strategies.
Only now are we learning the staggering cost of child malnutrition and stunting.
The impact of a stunted child, particularly the economic cost, rolls through time and across societies and around the world like the ripples that spread from a single pebble cast into a pond.
The ripples of a stunted child spread from the individual to the family to the community to the country to entire continents to the whole world.
The costs begin with the individual. 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 five decades has found that children who were well nourished in the 1,000 days completed a couple more grades of school than malnourished children. As adults, the better nourished group earned 20–40% more in wages, and they were less likely to develop a chronic illness.
Next, the impact spreads to the family of the stunted child, which will have one more person earning less than a full wage who will likely incur higher healthcare costs than would otherwise be necessary, making the family's climb out of poverty that much more difficult. For many families, the impact of malnutrition and stunting steamrolls through the generations in an accumulation of historical insults: stunted girls grow up to be stunted women who give birth to underweight babies. The cycle spins on.
The ripples from stunting then widen to engulf the community, for where there is one malnourished child, there are certainly more. Labor pools are depleted, productivity is sapped, economic growth lags.
In the same way, entire countries and continents are crippled. Nations with high child stunting rates—in more than 70 countries, at least 20% of children are stunted—calculate that they annually lose between 5% (Guatemala and Uganda) and 16% (Ethiopia) of their gross domestic product to low labor productivity, high healthcare expenditures, and other impacts of malnutrition. Sub-Saharan Africa and South Asia—where aggregate malnutrition stands at about 40% and stunting is the highest in the world—each lose an estimated 11% of gross national product every year.
Why do some countries and regions of the world remain poor? Because their mothers and children are malnourished and stunted. They have a lousy first 1,000 days.
The impact of malnutrition in the 1,000 days is not limited to the poorest places on the planet. China and India, the world's two most populous countries, both important drivers of the global economy, are experiencing a significant and escalating impact. For all its billionaire businessmen, high-tech progress, and Bollywood glamor, India has some of the world's highest stunting and malnutrition rates; about half of its children younger than 5 years have low height and weight for their ages. Those physical measures are often signifiers of diminished mental development as well. India's geopolitical position and potential economic power reside in its immense population—more babies are born in India every year than anywhere else—and the demographic dividend it should reap as all these children go to school and become well-educated working adults. But because so many of those children are born underweight to malnourished moms and grow up stunted, carrying the penalties of a poor first 1,000 days throughout their lives, that demographic dividend threatens to become a demographic disaster.
Similarly, obesity is beginning to weigh heavily on national economies. Because stunted children have a higher propensity to be obese as adults (their bodies are conditioned to conserve calories and fat), India now also has one of the fastest growing obesity rates in the world. It is an emerging phenomenon: the crippling double burden of malnutrition. In China, a country once plagued by famine and vast hunger, the future economic costs of obesity are projected to more than double, rising from 4% of gross national product in 2000 to 9% in 2025.
And in the United States, where obesity rates have more than doubled in adults and children since the 1970s, the burden has become a leading public health problem, with escalating cases of diabetes and other chronic diseases as well as burgeoning healthcare costs. It is a peculiar American paradox: although more than half of adults and nearly one-third of children and adolescents are overweight or obese, about 19% of households are food insecure, which means that at some point in the year they are uncertain they can afford the next meal.
One in every five children in the United States is in a family dependent on food stamps; for them, meals often consist of the cheapest food available, which usually means the least nutritious. In 2014, hunger and food insecurity increased health expenditures in the United States by at least $160 billion, according to a study published in Bread for the World Institute's annual hunger report.
And consider this: An organization of retired officers of all branches of the U.S. military, called Mission:Readiness, published a report called “Too Fat to Fight.” It finds that about 70% of Americans between the ages of 17 and 24 are unfit for military service, mainly because they are overweight or obese (in addition to other reasons, like being undereducated or having a criminal record). The report clearly finds that malnutrition is a threat to our nation's security. The military officers point to the importance of the 1,000 days, and children getting off to a good start in life, as key to national defense.
As we see, no country in the world, no matter how rich or mighty, is immune to the insidious impact of malnutrition.
Which brings us to the final ripple:
The cumulative toll of these individual, family, community, and national costs imposes a significant drag on global productivity, international trade, and healthcare, stunting the world economy by as much as 5%. That is the equivalent of several trillion dollars in economic activity, squandered every year.
The ripple of malnutrition engulfs us all. A stunted child anywhere is a stunted child everywhere.
But the greatest costs of malnutrition and stunting, I believe, are immeasurable:
A poem not written. A song not sung. A novel not imagined. A gadget not invented. A building not designed. A mystery not solved. A horizon not explored. An idea not formed. An inspiration not shared. An innovation not nurtured. A cure not discovered. A kindness not done.
What might a child have contributed to the world if he or she had not been stunted in the 1,000 days? A lost chance of greatness for one is a lost chance for all.
This is why your work matters. If we are to truly shape the world, to change the world, it begins in the first 1,000 days, with the first food and good nutrition. The world cannot end poverty and inequality without it.