In the short-term, being stunted means a child is more likely to get, and then five times more likely to die of, diarrhea. And it is a vicious cycle. Just five episodes of diarrhea before a child’s second birthday can lead to stunting.
The long-term picture is even more shattering. A stunted child’s brain development is so severely affected by the lack of nutrients that they are likely to be cognitively impaired for life by school achievement, economic productivity in adulthood and maternal reproductive outcomes. It means malnutrition does not affects the child weight and height alone but also affects the child’s intellectual abilities and therefore a nation’s potential success.
According to the Global Nutrition Survey 2018 Report which reveals that Asia is one of the hardest-hit areas when it comes to malnutrition although the region experienced the largest reduction in stunting from 2000 to 2017 – from 38 % to 23 %. The report found that the three countries with the largest number of children who are stunted are India, Nigeria and Pakistan.
Pakistan Demographic Health Survey (PDHS) 2017-2018 indicated, 38 percent children under five are stunted and out of 38 % slightly more than half (17%) are severely stunted in Pakistan.
According to the World Bank, a 1 percent loss in adult height due to childhood stunting is associated with a 1.4 percent loss in economic productivity. It is estimated that stunted children earn 20 percent less as adults compared to non-stunted individuals.
It’s beyond diarrhea and nutrition
Our Prime Minister Imran Khan’s inaugural speech about stunting caught my attention as a health economist. It was heartening for me to hear importance of child growth and development being addressed at a national level in such detail. Mr. Prime Minister stated, Pakistan is among the top five countries globally where children under 5 dying because of drinking dirty water namely diarrhea.
In order to tackle the shocking statistic, in the past decades many researchers around the globe have worked to reduce the burden of child diarrheal disease specifically in resource limited countries. Their work did culminate in a reduction of diarrheal disease however; the stunting rate under five did not change as much as expected. To some extent the prevailing situation has progressed in Pakistan but it is significant to notice that diarrhea is not the only problem.
World Health Organization (WHO) has estimated that nutrition-related factors contribute to almost half of all deaths among children under five worldwide. If stunting is used as a clinical indicator of under nutrition, 38% of all Pakistani children are yet stunted despite several nutritional and hygiene-related interventions.
It was observed that children were still getting stunted though adequate nutrition, hygiene and vaccination were upgraded. It indicates towards several other factors; those have created chronic malnutrition. The most persistent and foremost factor underlying stunting is poverty and food insecurity.
In fact, causes of stunting can be attributed to poverty, drinking unclean water, lack of proper early stimulation, food insecurity, anemia in mothers, early marriage leading to early pregnancies, deprived health services etc.
According to the Global Nutrition Survey 2018 Report which reveals that Asia is one of the hardest-hit areas when it comes to malnutrition although the region experienced the largest reduction in stunting from 2000 to 2017 – from 38 % to 23 %. The report found that the three countries with the largest number of children who are stunted are India, Nigeria and Pakistan
Risk factors for childhood stunting in Pakistan
Stunting is also inversely related with wealth quintile. PDHS 2017-2018 report has appraised that, 57% of children in the lowest wealth quintile are stunted as compared to the 22% of children in the highest quintile,
Poor and unhygienic living conditions, little access to safe water and adequate sanitation scenario exposes children to high rates of intestinal infections and diarrhea. Recent data from a WaterAid report (2017) assessed that 79 million people lack a decent toilet, while 37% have no system for wastewater disposal in Pakistan.
Additionally, a major contributor to childhood malnutrition is the overall poor state of infant and young child feeding. Breastfeeding is sufficient and beneficial for infant nutrition in the first 6 months of life even with 37% of infants under the age of 6 months are fed using a bottle with a nipple, a practice that is discouraged because of the risk of illness to the child. 54% of children age 6-8 months received timely complementary foods, while 44% of children age 18-23 months has been weaned according to PDHS 2017-2018.
Being food insecure is also one of the key contributors to poor nutritional status. An average Pakistani household spends 50.8 percent of monthly income on food. According to USAID “Food assistant Fact Sheet 2018, approximately 60% t of the Pakistani population is facing food insecurity, though Pakistan has become a food surplus country and a major producer of wheat and rice. However, the poorest and most vulnerable members of the population cannot afford a sufficient and nutritious diet despite the overall growth in food production.
What will it take to end child stunting?
No doubt; a critical factor that considers on the magnitude of stunting is hygiene and sanitation, which largely affects the household environment. Water and sanitation investments have a huge potential to improve nutrition outcomes. But it cannot be overruled that ending child stunting is a multi-sectoral challenge. Tackling child stunting requires a multi-sectoral effort that, in turn, requires individual, institutional and system-level collaborators to implement effective interventions through engagement across different stakeholders (including civil society organization and the private sector) and, sectors (e.g. health, social protection, agriculture, education) and different levels of involvement (e.g. planning, implementation monitoring, evaluation).
To improve child nutrition and reduce stunting, it is imperative to focus on other parallel factors; it is not just about getting more food, but ensuring that mothers and young children get the right foods with the right vitamins and minerals at the right times during the critical growth window in the first 1000 days. We must focus on what is called the ‘first thousand days’ – that is the time from conception of a child to two years of age. In this period, stunting is preventable and reversible. If fast reductions in stunting are to be achieved, the focus must be mostly, on a handful of activities that have immediate effect on pregnant women and their babies during this period. Nutritionally, it is important that pregnant women take iron, folic acid and multivitamins. By ensuring that women take iodized salt, breastfeed within one hour of birth and then only provide breast milk to their babies for the first six months – nothing else, no formula, no goat’s milk and certainly no water – we can help children get an early start in life.
Beyond these measures, longer-term planning can mitigate the issues leading to stunting in the first place. For example, early childhood education programs, full immunizations for all, widespread treatment of diarrhea, clean water and latrines, to name just a few.
Pakistan faces an immense challenge given the absolute numbers of children suffering by from stunting. Pakistan currently has 15 percent of its population, or about 25 million children, between 0-4 years of age. These children are the country’s future. If they are stunted today during a critical period of their development, Pakistan will continue to be stunted for the predictable future. Therefore, improving child nutrition is one of the best and most critical investments that Pakistan can make.
The writer is a Project Assistant at Sustainable Development Policy Institute
Published in Daily Times, February 19th 2019.