The year was 1975. I was a final year medical student in Pondicherry, South India. I was going for my practical test on Preventive and Social Medicine (PSM). PSM was (and probably still is) one of the least favorite subjects in the medical curriculum for most students. “Why should we prevent diseases? If we prevent all diseases what will we all do with our medical degrees? Isn’t that professional suicide?” asked one of my class-mates! But I digress. Coming back to the test, I was unusually nervous because I had not studied everything well. For some reason, one chapter that I did study the night before was nutrition. I had also volunteered for two months in a Nutrition Rehabilitation Center (NRC) which meant that it was one chapter that I was more confident about. As my luck would have it, every single question that the examiner asked me that day was on nutrition! I blasted my way through the test, and thanked my stars for that exceptional bit of good fortune. From that day, nutrition has always been close to my heart.
The NRC is a somewhat outdated concept nowadays. The idea was to have a malnourished child and mother live for a month in the NRC and learn good household behaviors that could result in better nutritional outcomes.
The NRC was set in the medical college campus, but in an environment similar to rural areas; the homes were thatched huts, with mud-floors, but kept very clean, a hand-pump for water supply, sanitary latrines, a small piece of land attached to the hut for kitchen-gardens, etc. – what one might see if we went to a “model village” in India (such model villages were developed even in those days to showcase what can be done with limited resources). Most kids who were brought into the NRC had been first treated for severe malnutrition and its consequences, in the pediatric ward of the teaching hospital. They had been brought back from the edge of death by intravenous nutrition and antibiotics; now it was time to rehabilitate them in a setting similar to their home, and teach their mothers what they can practice within their own resources. NRCs were effective – for the specific children and mothers who experienced them. But what proportion of the population could benefit from such an approach? Is it possible to bring the millions of women and children to live in an NRC for a month? The expected domino effect of these mothers returning to their communities and changing behaviors did not really happen.
We have come a long way from NRCs in the concept and design of community-based nutrition interventions. My next serious rendezvous with nutrition was soon after I joined the World Bank in 1991. I happened to work on Bangladesh, which had extremely high levels of malnutrition (this is still the case, though the rates have come down somewhat). We began the dialogue process with the Government and the many donors milling around the health sector in Bangladesh. Back then, I had lots of energy, but not much tact (my colleagues might say that now I have little of either). But the good part is that being a junior member of the team, I did not have much chance to speak; so not much damage was done. But I did get a chance to work with some real international stalwarts in nutrition and learn richly from them. I am eternally thankful for that learning, which I cherish to this day. After a year or so of my working in the team, the then task-manager handed the project preparation over to me. That was the first project I would take to the Bank’s Board. And what a journey it was!
One might think that the World Bank offering about $60 million to address malnutrition in women and under-five children of Bangladesh should not face much opposition. One would be dead wrong! Except for UNICEF, no other donor was interested; what’s more, some of them actively opposed the idea and even took a vigorous stand against the Bank-financed proposed project. As for the Government, fortunately, we had a progressive thinking leadership in the Ministry of Health and Family Welfare, willing to act, but that did not mean a lack of challenges. Nutrition being “everybody’s business and nobody’s responsibility” (I know it is a cliché, but it is true!), there were turf battles, conflicting positions and down-right backstabbing politics standing in the way of this seemingly harmless project proposal. Some donors argued that the priority in Bangladesh was to control the population growth (refusing to see the well-known point that improved child nutrition leads to better child survival, in turn making parents more willing to adopt family planning); others said that improving health services was the best way to address nutrition; yet others felt that improved food production would be the ultimate answer; some argued that nutrition cannot be improved as long as Bangladesh was poor. But to bring a consensus around the issue was a Himalayan task. (It is almost like the health reform debate in the US today!)
Nearly thirty-five years ago, I could understand under-nutrition in South Asia (partly because I did not know better then). Being a poor sub-continent, we assumed – and alas, accepted – that malnutrition was a given. But let’s take India for instance. Since then, India has changed considerably in economic and developmental terms. Today’s per capita GDP in India is almost four times what it was in 1975. Health indicators have also improved as also literacy rates. But childhood nutritional status is not correspondingly better. The same story is true of most of South Asia to varying degrees. Sri Lanka is even starker with the economic growth and even health status improvements not reflecting in nutritional indicators. The story in Nepal, Pakistan and Bangladesh – though their economic growth may be comparatively less remarkable – is quite similar in broad terms. This was evident even back then in 1992 when we looked at the Bangladesh scenario (and Tamil Nadu, which was a fore-runner of the Bangladesh program had already found the same picture). And, many African countries with much lower income levels have better nutrition status. In the current context of South Asia – economically, developmentally, and health-wise – I believe that childhood and maternal undernutrition is entirely avoidable, absolutely unacceptable and even immoral.
Barring the hard-core poor, I don’t buy the idea that poverty must necessarily result in undernutrition. Conversely, poverty eradication is not a pre-requisite for better nutrition (rather, improved nutrition would help alleviate poverty). I have been to poor households in Bangladeshi villages to find that the man in the household is quite well-nourished, the woman is less so, a five-year old boy is catching up on his growth rate (though he can never regain the lost development of his first two years) and there is a 13 month old baby obviously under-weight. If there is enough food in the household to feed the grown-up man, how come the household does not have enough food for the little 13-month old? How much food does the little baby need, relative to the others in the family? The growth charts of under-five children tell a remarkable story (see schematic diagram below). Starting with a low birth weight and growing at a slower rate, the child’s growth line keeps going further away from the norm until 24 months; after 2 years of age, however, the growth rate picks up and runs almost parallel to the norm, though still below in absolute terms. So, while the baby cannot regain the lost ground, the pace becomes normal. The basic difference is: “over-two children eat, while under-two children need to be fed.” Bottom-line: Nutrition does not equal food. In fact, nutrition does not equal feeding either; good nutrition is the result of myriad factors – good food and feeding being the most obvious ones. Access to good health services, hygiene and sanitation, caring practices such as childhood stimulation are less obvious but no less important.
Equating nutrition with food is perhaps one of the most damaging ideas for the cause of nutrition, especially in South Asia, where non-food factors play such a crucial role. Similarly equating economic growth with children’s growth is a big mistake. Yes, food insecurity in poor households is an issue to be addressed. But addressing household behaviors, feeding and caring practices, gender issues and other socio-cultural factors, as well as hygiene and sanitation is perhaps a more urgent and often neglected aspect of nutrition programs in South Asia. That is where our attention needs to be focused.
At the time of preparing the Bangladesh Integrated Nutrition Project (BINP), nearly $600 million dollars had been invested by donors on the health sector. And about the same amount was being spent on food and agriculture programs. $60 million per year was being spent on free food rations – ostensibly to the rural poor – later abandoned due to its leakage rate of around 90%. There were several other food programs. There was little or no investment in behavior change. BINP therefore chose to focus on this investment gap, against much opposition. Ironically, the same folks who criticized the project for not including enough food security interventions also opposed the supplementary feeding included in it (for demonstrative effect). But the partnership between the Government, UNICEF, and World Bank was very strong. Senior government officials visited a few nutrition programs internationally, including Integrated Child Development Scheme and the Tamil Nadu Integrated Nutrition Project and chose the latter design. The core of that design is to change household behaviors through intensive community-based action, which considerable positive externalities on the social and gender front. The project also introduced – probably for the first time ever in the Bank – NGO contracting using IDA funds. The project was also one of the first to have a fairly robust M&E system; the person who designed that M&E system is currently the Lead Nutrition Person in the Bank. Unfortunately, the project was scaled up precipitously, without waiting for lessons learned, and the successor project (National Nutrition Project) became even more controversial.
Now finally, no one (well, no reasonable one) can dispute the priority that Nutrition deserves in development work, or in poverty alleviation. In fact, some economists even consider malnutrition as a dimension of poverty (not just a cause or an effect). The debate still rages on, however, on how best to address the problem. I believe that the key is in community-based interventions, using local women’s groups, which can bring positive changes to household level practices on feeding, eating, caring, stimulating babies’ growth, and hygiene. I believe that a life-cycle approach that starts with adolescent girls, and covers pregnant women, low birth weight children, lactating mothers and under-two children would be the most effective. I believe that the malnutrition cannot be addressed by any one sector, and various disciplines must pull together; the nutrition community and the early childhood development experts must work in harmony, as the outcomes that they are working towards are inseparably intertwined. I believe that appropriate age-targeting is a critical success factor. Targeting 3-6 year old kids is simply too late to make a significant difference. I also believe take-home food rations don’t work. Programs that are conducted in community women’s groups, where growth monitoring and promotion is done as part and parcel of social activity are more likely to work. But then, many may not agree with me; if you have a different viewpoint – any viewpoint – on this issue, please comment, react, criticize, agree or disagree. Even among those who do agree on such an approach, there is no agreement on implementation modalities, which remain a challenge. In this regard, I believe that Civil Society involvement is an important piece of that puzzle; we need the innovation, dedication, commitment, pragmatism, activism and advocacy that non-governmental and community-based organizations bring. And that is the reason for this South Asia Development Marketplace!
Photos Courtesy of (c) Andrew Biraj