State of the World's Children 1998
Carol Bellamy, Executive Director, United Nations Children's Fund
1 Basic indicators
5 Demographic indicators
6 Economic indicators
8 The rate of progress
Measuring human development
Regional summaries country list
Statistics, vital indicators of the care, nurture and
resources that children receive in their communities and
countries, help chart progress towards the goals set at the
1990 World Summit for Children. The eight tables in this
report have been expanded to give the broadest possible
coverage of important basic indicators for nutrition, health,
education, demographics, economic indicators and the
situation of women, plus rates of progress and regional
summaries. They also include complete data, as available, on
less populous countries, covering 193 countries in all,
listed alphabetically. Countries are shown on page 93 in
descending order of their estimated 1996 under-five mortality
rates, which is also the first basic indicator in table 1.
1 Vitamin A supplements save pregnant women's lives
2 What is malnutrition?
3 Stunting linked to impaired intellectual development
4 Recognizing the right to nutrition
5 Growth and sanitation: What can we learn from chickens?
6 Breastmilk and transmission of HIV
7 High-energy biscuits for mothers boost infant survival by
50 per cent
8 UNICEF and the World Food Programme
9 Triple A takes hold in Oman
10 Celebrating gains in children's health in Brazil
11 Rewriting Elias's story in Mbeya
12 Women in Niger take the lead against malnutrition
13 BFHI: Breastfeeding breakthroughs
14 Tackling malnutrition in Bangladesh
15 Kiwanis mobilize to end iodine deficiency's deadly toll
16 Indonesia makes strides against vitamin A deficiency
17 Making food enrichment programmes sustainable
18 Zinc and vitamin A: Taking the sting out of malaria
19 Protecting nutrition in crises
20 Progress against worms for pennies
21 Child nutrition a priority for the new South Africa
Ten steps to successful breastfeeding
Fig.1 Malnutrition and child mortality
Fig.2 Trends in child malnutrition, by region
Fig.3 From good nutrition to greater productivity and beyond
Fig.4 Poverty and malnutrition in Latin America and the
Fig.5 Causes of child malnutrition
Fig.6 Inadequate dietary intake/disease cycle
Fig.7 Intergenerational cycle of growth failure
Fig.8 Better nutrition through triple A
Fig.9 Iodine deficiency disorders and salt iodization
Fig.10 Progress in vitamin A supplementation programmes
Fig.11 Measles deaths and vitamin A supplementation
Fig.12 Zinc supplementation and child growth (Ecuador, 1986)
Fig.13 Maternal height and Caesarean delivery (Guatemala,
Summary: Malnutrition: Causes, consequences and solutions
Fact Sheet: Summing up malnutrition's shame
Fact Sheet: Malnutrition: Causes
Fact Sheet: Micronutrients
Feature: Child malnutrition and women's rights
Feature: In Burundi camps, the spetre of malnutrition looms
Feature: Malnutrition in industrialized countries
The state of the world's children 1998 - Chapter II
Administrative Committee on Coordination/Subcommittee on
acquired immune deficiency syndrome
Latin American Millers Association
acute respiratory infections
Baby-Friendly Hospital Initiative
Bangladesh Rural Advancement Committee
Child Survival and Development Programme (Tanzania)
Economic Commission for Latin America and the Caribbean
Food and Agriculture Organization of the United Nations
gross domestic product
growth monitoring and promotion
gross national product
Health and Nutrition District Support (Tanzania)
human immunodeficiency virus
International Council for the Control of Iodine Deficiency
iodine deficiency disorders
International Fund for Agricultural Development
International Monetary Fund
Institute of Nutrition of Central America and Panama
Medical Research Council (UK)
Micronutrient Initiative (Canada)
National Center for Health Statistics
official development assistance
oral rehydration salts
oral rehydration therapy
under-five mortality rate
Joint United Nations Programme on HIV/AIDS
United Nations Development Programme
Office of the United Nations High Commissioner for Refugees
United Nations Children's Fund
United States Agency for International Development
World Alliance for Breastfeeding Action
World Food Programme
World Health Organization
Note: all dollars are US dollars.
* * * *
The State of the World's Children 1998 - Press kit
Malnutrition: Causes, consequences and solutions
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
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
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
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,
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
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
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
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
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
And under the Convention's pre-eminent principle, good child
nutrition is a right because it is in the "best interests of
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
Malnutrition: Spotlighting the causes
An understanding of the causes of malnutrition is important
to appreciating the scale and depth of the problem, the
progress achieved to date and the possibilities for further
progress that exist.
The interplay between the two most significant immediate
causes of malnutrition - inadequate dietary intake and
illness - tends to create a vicious circle: A malnourished
child, whose resistance to illness is compromised, falls ill,
and malnourishment worsens.
Three clusters of underlying causes lead to inadequate
dietary intake and infectious disease: inadequate access to
food in a household; insufficient health services and an
unhealthful environment; and inadequate care for children and
* Household food security
This is defined as sustainable access to safe food of
sufficient quality and quantity to ensure adequate intake and
a healthy life for all members of the family. Household food
security depends on access to food as distinct from its
availability. There may be abundant food available on the
market, but poor families that cannot afford it are not food
* Health services, safe water and sanitation
An essential element of good health is access to affordable,
good quality health services. In as many as 35 of the poorest
countries, however, 30 to 50 per cent of the population may
have no access to health services at all. The lack of ready
access to a safe water supply and proper sanitation and
unhygienic conditions in and around homes have significant
implications for the spread of infectious diseases. More than
1.1 billion people still lack access to safe water, and about
2.9 billion people lack access to adequate sanitation.
* Caring practices
Care is manifested in the ways a child is fed, nurtured,
taught and guided and is the responsibility of the entire
family and the community. The following caring behaviours are
Feeding: Breastfeeding provides the best nourishment and
protects children from infection. However, a child must have
complementary foods at the six-month point, since breastmilk
no longer meets all nutritional needs. From about 6 months to
18 months of age, the period of complementary feeding, a
child needs frequent feeding - at least four times daily -
and requires meals that are both dense in energy and
nutrients and easy to digest.
Protecting children's health: Children must receive essential
health care at the right time. Immunizations, for example,
have to be carried out according to a specific schedule.
Sound health information needs to be available to
communities, and families need to be supported in seeking
appropriate and timely health care.
Providing emotional support and cognitive stimulation for
children: For optimal development, children require emotional
support and cognitive stimulation from parents and other
caregivers. Several studies have found that malnourished
children who were given verbal and cognitive stimulation had
higher growth rates than those who were not.
Caring for and supporting mothers: The unequal division of
labour and resources in families and communities that favours
men jeopardizes the well-being of both children and women.
The elements of care most critical for women during pregnancy
and breastfeeding include extra quantities of good-quality
food, release from onerous labour, adequate time for rest,
and skilled pre- and post-natal health care from trained
Political, legal and cultural factors may defeat the best
efforts of households to attain good nutrition. These include
the degree to which the rights of women and girls are
protected by law and custom; the political and economic
system that determines how income and assets are distributed;
and the ideologies and policies that govern the social
* * *
Overcoming entrenched poverty and underdevelopment requires
resources and inputs that few developing countries can
muster. In 1995, aggregate resource flows to the developing
world from all sources totalled $232 billion, with $156
billion of that from private investment and loans. Yet the
two regions of the world with the highest rates of childhood
malnutrition - sub-Saharan Africa and South Asia - received
only $1.6 billion and $5.2 billion respectively.
At the same time, developing countries overall owed more than
$2 trillion in external debt in 1995. If the basic causes of
malnutrition are to be addressed, greater and better-targeted
resources and better collaboration are needed between
sections of national governments and between governments and
all development partners, including donors, UN agencies, non-
governmental organizations (NGOs) and investors. Above all,
the poor themselves must be a major part of the process.
Action against malnutrition is both imperative and possible.
The world, as the next part of this report explains, has
already accumulated a wealth of experience and insight on
which progress can be built.
Approaches that work
For nutrition to improve, many factors are necessary. A
recent study by the United Nations, which confirmed that
there is no one formula to follow, had this is to say about
some of the factors that are essential:
Nutrition and economic growth: Most countries in which
nutrition has improved over the last two decades also enjoyed
relatively high rates of economic growth over a sustained
period. Where economic growth has resulted in increased
household income and resource access for the poor, the
nutritional pay-off has been large. In Indonesia, for
example, economic growth from 1976 to 1986 was accompanied by
a 50 per cent rise in the income of the poorest 40 per cent
of the people. Improvements in nutrition were relatively
constant throughout the economic boom, although they could
have been even better.
But while economic growth must be understood as a frequent
contributor to nutrition improvement, it is not a necessary
condition for it.
Nutrition and the status of women: Where nutrition
improvement has lagged behind economic growth, social
discrimination against women is common. The high rates of
child malnutrition and low birthweight in much of South Asia
are blamed by some experts on such factors as women's poor
access to education and low levels of participation in the
paid workforce, compared with other regions. In Thailand,
where nutrition has improved remarkably in the last two
decades, women's rates of literacy and participation in the
labour force are high, and women have a strong place in
social and household-level decision-making.
Nutrition and social-sector spending: Investments in health,
education, sanitation and other social sectors - especially
with an emphasis on access of women and girls to these
services and resources - are among the most important policy
tools for improving nutrition. Evidence comes from Zimbabwe,
where explicit policies were followed to redress the lack of
access of many communities to basic services after
independence in 1980.
* * *
Actions that concentrate on nutrition improvement may have a
more rapid and focused effect. A number of these more direct
approaches that have worked are described below.
In villages in the Iringa region of Tanzania, a seemingly
modest process began in the early 1980s when villagers, many
of them in poor and remote areas, began to track the weight
of their children. With financial support from the Government
of Italy and day-to-day technical support from UNICEF, the
Child Survival and Development Programme eventually reached
more than half the population of Tanzania. Severe
malnutrition virtually disappeared, and mild and moderate
malnutrition was greatly reduced, saving the lives of
thousands of children. A major feature of the programme was
community-based growth monitoring, which helped people
understand the problems that cause malnutrition and take
actions to solve them - called the triple A' approach. The
programme did not increase the production or availability of
basic food, therefore the success achieved suggests that an
overall lack of food at the household level was not the major
cause of malnutrition in young children and pregnant women in
In Thailand, another success story
On the other side of the globe, Thailand has improved the
nutrition of millions of its children through a combination
of approaches, aided by a booming economy. According to the
Government, malnutrition of under-five children fell from
about 51 per cent in 1982 (measured as a proportion of
underweight children) to about 19 per cent in 1990, and
severe malnutrition virtually disappeared during that period.
A number of policy and programme measures contributed to
reducing both malnutrition and poverty. Targeted to poorer
regions, these included school lunch programmes, surveillance
of basic minimum needs' indicators, village-level planning
to ensure that priority needs were met, rural job creation
and support for small-scale food producers.
Protecting, promoting and supporting breastfeeding
Virtually all programmes that have reduced malnutrition have
focused on improvements in infant feeding, especially the
protection, promotion and support of breastfeeding.
Inappropriate advertising and promotion by manufacturers of
breastmilk substitutes - mostly infant formula - have been a
central challenge in this regard.
In 1981, the World Health Assembly, comprising the health
ministers of almost all countries, adopted the International
Code of Marketing of Breastmilk Substitutes. Drafted by WHO,
UNICEF, NGOs and representatives of the infant food industry,
the Code establishes minimum standards to regulate marketing
practices, stipulating in particular that health facilities
must never be involved in the promotion of breastmilk
substitutes and that free samples should not be provided to
pregnant women or new mothers.
Progress has been relatively slow in translating the Code's
minimum provisions into national laws. As of September 1997,
only 17 countries had approved laws that put them into full
compliance with the Code. Training and development of model
legislation are now accelerating action in this area.
To help support breastfeeding, UNICEF and WHO in 1991 began
an intensive effort to transform practices in maternity
hospitals. The Baby-Friendly Hospital Initiative (BFHI), as
the effort is called, has, in just six years, helped
transform over 12,700 hospitals in 114 countries into centres
of support for good infant feeding.
Tackling specific nutritional deficiencies
It is impossible to separate protein-energy malnutrition from
vitamin and mineral deficiencies, and reductions in overall
malnutrition have usually been achieved by addressing both
micronutrient and protein-energy deficiencies. But progress
has been more rapid in reducing some deficiencies than
Grains of salt: Reducing iodine deficiency disorders
The reduction in iodine deficiency, the world's most
important cause of preventable mental retardation, is a major
global success story. Of the countries that had iodine
deficiency problems in 1990, 26 now iodize over 90 per cent
of their edible salt. Another 14 countries iodize between 75
and 90 per cent of their salt. It is estimated that up until
1990, about 40 million children born each year were at some
risk of mental impairment caused by iodine deficiency in
their mothers' diets. By 1997, that figure was probably
closer to 28 million. The number of children born each year
with cretinism is difficult to estimate - but in 1990 it was
on the order of 120,000. It is probably about half that now.
Capitalizing on vitamin A's benefits
Although the value of vitamin A for protecting children
against blindness has been known for decades, vitamin A's
amazing ability to strengthen resistance to infection and
reduce the chances of children dying has only recently won
general acceptance by the scientific and medical
Several approaches exist to prevent vitamin A deficiency that
can be highly effective if applied in complementary ways.
These include supplements (commonly administered in capsule
form), fortification of food and improving diet through
gardening or other methods.
By mid-1997, the policy of providing children with periodic
high-dose supplements was adopted in all but 3 of the 38
countries where clinical vitamin A deficiency still existed -
and in all but 13 of the additional 40 countries with
documented subclinical deficiency.
Overall, UNICEF estimates that more than half of all young
children in countries where vitamin A deficiency is known to
be common received high-dose vitamin A capsules in 1996,
compared to about one third in 1994, including such large
countries as Bangladesh, India, Nigeria and Viet Nam. At
roughly 2 cents per capsule and 20 to 25 cents per delivered
dose, few other child health or nutrition interventions are
as cost-effective in reducing mortality and disability
throughout life as vitamin A supplements.
In many countries, vegetable gardens and various food
preservation and preparation methods that enhance the vitamin
content of diets have been promoted as means of improving
vitamin A intake.
Responding to anaemia
Iron deficiency anaemia is probably the most prevalent
nutritional problem in the world. Over half the women in
developing countries and a large percentage of young children
suffer from it, and progress in reducing its prevalence and
impact has been slower than might be hoped.
Many countries have adopted policies to ensure that women who
seek prenatal care have access to daily iron supplements to
help them meet the very high needs of pregnancy and
childbirth. UNICEF is a major supplier of iron/folate tablets
- a total of 2.7 billion were provided to 122 countries from
1993 to 1996.
Fortifying foods with iron is also an effective means of
addressing anaemia. Wheat flour and flour products are the
most common vehicles for iron fortification in places where
they are widely consumed and centrally processed,
particularly in Latin America and the Middle East.
Improving basic health services
The nutritional well-being of children around the world has
benefited greatly from the enormous improvements made since
1990 in access to basic health services for children. By
1996, more than 90 per cent of children were immunized in 89
countries and over 80 per cent in another 40 countries,
including a 79 per cent global measles immunization rate,
protecting children from preventable diseases as well as
leaving their vitamin A levels undisturbed.
In addition, over 1 million children are saved each year from
death due to dehydration caused by diarrhoea, through the use
of oral rehydration therapy (ORT).
An especially important advance has been the revitalization
of basic health services through such measures as the Bamako
Initiative, launched by African governments in 1987 in
response to the rapid deterioration of public health systems
in Africa in the 1970s and 1980s, and now operating in other
With WHO and other partners, UNICEF is committed to
accelerated action in malaria control, including the use of
insecticide-treated bed nets and support for improved drug
use in malaria treatment. A combined programme for the
prevention of both iron deficiency anaemia - through iron
supplementation, fortification and dietary improvement - and
parasite-induced anaemia - through malaria control and
deworming - is one emerging approach for effectively
addressing these age-old problems.
Programmes featuring improved education and information
School-based programmes and non-formal programmes for youth
and adults, such as literacy and parent education courses,
are useful complements and sometimes a principal vehicle for
promoting better nutrition. Schools, teachers and education
programmes can also mobilize community participation in many
ways, such as through village education committees and
Eight useful lessons
There is no single prescription, but eight points bear
1. Solutions must involve those most directly affected.
People who suffer or whose children suffer from malnutrition
cannot be passive recipients of programmes. Problems must be
assessed with the full and active participation of the
families most threatened by nutritional problems and most
familiar with their impact and causes.
2. A balance of approaches is necessary.
A central challenge for nutrition programmes as well as other
development efforts is finding a balance of approaches that
work. Processes involving assessment, analysis and action -
the triple A' approach - are essential for formulating
appropriate bottom-up' solutions, particularly with respect
to the ways in which programmes are organized, managed and
monitored. But there are some aspects of resolving
malnutrition that can be appropriately formulated at higher
levels, using more top-down' application of strategies and
technologies, based on the scientific knowledge and the most
effective technologies available. A combination of top-down
and bottom-up actions may be best, as demonstrated by BFHI in
promoting breastfeeding, experience with vitamin A
supplementation efforts and progress in salt iodization.
3. Nutrition components work better in combination.
Malnutrition is the result of many factors, and it has been
attacked most effectively in situations in which several
sectors and strategies have been brought to bear. Combining
improved infant feeding with better household access to food
and more accessible health services and sanitation is clearly
more effective in reducing malnutrition than any one of these
Communication plays a special role in nutrition programmes in
arming parents, other caregivers and educators with basic
nutrition information, the ability to make informed decisions
and the skills and knowledge needed to take action to support
improved nutrition in their communities.
4. Progress hinges on continuing research.
Gains against malnutrition have depended on relevant
research, but more is needed. For example, it took the urging
of United Nations agencies and financing from the Government
of Canada to ensure that the impact of vitamin A deficiency
on mortality was analysed. Also, research institutions, both
industry-based and academic, need to include the poor and
their day-to-day nutrition problems on the research agenda.
5. Food production is important but not enough.
As was demonstrated in Tanzania, nutrition can be improved
even in poor communities without increasing overall food
availability. Increasing food production, while often
necessary, is never enough to ensure nutrition improvement.
6. Everyone has an obligation to child rights.
Children have a valid claim to good nutrition, and government
agencies and members of society, including parents, have
duties to realize this right. All people need to become aware
of the nutrition problem, its causes and consequences,
possible solutions and their obligation to respect, protect,
facilitate and fulfil this right. Advocacy, information,
education and training are important strategies to create or
increase this awareness.
7. Community and family-based involvement is vital.
If they are to care properly for their children, the poor
must be recognized as key actors rather than as passive
beneficiaries of commodities and services. All available
resources, even those controlled outside the community,
should be used to support processes within households and the
community to improve nutrition.
8. Government policies must reflect the right to nutrition.
Some national policies affect nutrition directly, such as
salt iodization or immunization programmes. Others, like
income and price policies, affect nutrition indirectly. With
the ratification of the Convention on the Rights of the
Child, governments have the obligation to respect, protect,
facilitate and fulfil the rights enshrined in the Convention.
All policies should therefore be analysed in terms of their
real and potential impact on the right to good nutrition.
Bringing science to bear
The successes stemming from breakthroughs in science and
technology have stirred new hope for healthier, more
productive lives for both children and adults. Following are
some of these advances that are helping to reduce
malnutrition - or that may do so.
Nutritionally acquired immune deficiency
The immune systems of some 23 million people worldwide have
been damaged by HIV, the virus that causes AIDS. It is less
well known that malnutrition impairs the immune systems of at
least 100 million young children and several million pregnant
women - none of them infected by HIV. But unlike AIDS, the
cure' for immune deficiency due to malnutrition has been
known for centuries: It is achieved by ensuring an adequate
dietary intake containing all essential nutrients. Today,
more is being learned about the specific role of individual
nutrients in the functioning of the immune system.
The results of a dozen field studies, conducted in Brazil,
Ghana, India, Indonesia, Nepal and elsewhere, indicate that
supplementing the diets of children who are at risk of
vitamin A deficiency can reduce deaths from diarrhoea by
35-50 per cent, and the vitamin can almost halve the number
of deaths due to measles.
Zinc is essential for the growth and development of cells and
for the functioning of the immune system. Trials have already
shown reductions of about one third in the duration and
severity of diarrhoea in children receiving zinc supplements
- and a median 12 per cent decline in the incidence of
pneumonia. In these investigations, zinc supplements did the
most good for the children who started out the most
malnourished. And new research indicates that even the
effects of malaria, a deadly enemy of both children and
adults, may be lessened by zinc and vitamin A.
Nutrition and AIDS
The role of nutrition in preventing infection is now being
investigated as one possible way to help reduce the
transmission of AIDS. Vitamin A may form part of the arsenal
needed to combat HIV, which is expected to infect between 4
million and 5 million children by early in the next century.
A 1994 study of HIV-infected women in Malawi found that 32
per cent of those who were vitamin A deficient during
pregnancy had passed HIV on to their infants. In contrast,
only 7 per cent of HIV-infected women with sufficient levels
of vitamin A did so. A 1995 study from Kenya reported that
the concentration of HIV in breastmilk is higher in vitamin
A-deficient mothers than in those with good vitamin A status.
Based on the findings of the first studies - and to
demonstrate whether the connection between vitamin A and HIV
transmission is causal - four clinical trials were begun
recently to examine HIV transmission rates in women who have
received vitamin A supplements during the second or third
trimester of pregnancy.
Using nutrition to reduce maternal deaths
Maternal mortality is a tragedy in social, economic and
public health terms, since the vast majority of the 585,000
yearly maternal deaths around the world are preventable.
Obstructed labour is more likely to occur among women who
were stunted in childhood. It is estimated that anaemia may
be responsible for 20 per cent of maternal mortality.
Programmes already exist to reduce anaemia in pregnant women,
but more work is needed to make iron/folate supplementation
programmes more effective and to improve the treatment and
prevention of malaria and hookworm, which contribute to
Other connections between nutrition and maternal mortality
suggested below are not yet definitively demonstrated but
hold great promise for the future.
* New findings have shown that improving the vitamin A
status of pregnant women whose intake of the vitamin is low
dramatically reduces maternal mortality.
* Zinc deficiency, increasingly recognized as widespread
among women in developing countries, is associated with long
labour, which increases the risk of death. Severe zinc
deficiency is also believed to impair foetal development in
several ways. A number of studies have found that zinc
supplementation reduces the complications of pregnancy.
* It has long been known that iodine deficiency in women
increases the risk of stillbirths and miscarriages. And there
is some evidence that in highly iodine-deficient areas,
another result of this deficiency may be increased maternal
mortality through severe hypothyroidism.
* One recent study showed that calcium supplementation did
not reduce the risk of hypertension in pregnancy that could
result in death, but a number of experts have suggested that
supplementation might reduce this risk in areas where women
are especially calcium deficient.
* Folate deficiency, now well known to induce neural-tube
birth defects if it is present during the first month of
pregnancy, may also represent a risk for maternal morbidity
and mortality, as well as increase the risk of low
Breastfeeding: Good for mothers' health, too
A number of studies have shown that initiating breastfeeding
immediately after birth, as most women do in baby-friendly
hospitals, stimulates the contraction of the uterus and
reduces blood loss. Also, a recent study in the United States
demonstrated that women who breastfed their children had a
lower risk of breast cancer in the pre-menopausal period, and
that the longer they breastfed, the lower the risk.
Prevention of chronic diseases
Chronic degenerative diseases, such as heart disease, are
largely regarded as diseases of affluence. Arguments are
being made, however, that these diseases may in large measure
also be diseases of poverty - particularly poverty early in
life and during foetal development. The hypothesis is
particularly intriguing in light of the fact that ischaemic
heart disease is projected to be the world's leading cause of
death and disability in the year 2020.
Over 30 studies around the world, for example, have indicated
that low-birthweight babies who were not born prematurely
have a higher incidence of hypertension later in life than
those with a normal birthweight. Low birthweight, as well as
thinness at birth, has also been correlated with glucose
intolerance in childhood and non-insulin dependent diabetes
in later life.
In central India, an ambitious study involving over 800 women
is exploring the impact that a mother's nutrition may have on
the development of diabetes, high blood pressure and heart
disease in her offspring when they reach adulthood. An
interesting early finding suggests that birthweights are most
strongly associated with the size of the mother - not only
her weight gain during pregnancy but also her weight, height,
percentage of body fat and head circumference before
conception. These early findings lend support to the premise
that building a sturdy baby depends on a life of good
nutrition for the expectant mother.
New ways to reduce malnutrition deaths in emergencies
In the last few years, a new protocol is improving the
treatment of severe malnutrition. This protocol recommends
milk for the early stages of therapeutic feeding, enhanced by
the addition of both oil and a vitamin and mineral mix, which
addresses the special micronutrient imbalance that
accompanies severe malnutrition. The new recommendations call
for modification of the standard oral rehydration salts (ORS)
to reduce the risk of heart failure in severely malnourished
children. Known as ReSoMal (rehydration solution for
malnutrition), it contains more potassium and different
concentrations of elements from those in standard ORS.
The new protocol also emphasizes the need for rapid attention
to clinical factors, such as low body temperature
(hypothermia) and low body sugar (hypoglycaemia), as well as
to less strictly medical factors such as meeting malnourished
children's great needs for emotional support, intellectual
stimulation and play.
New ways to measure malnutrition
Here are some of the promising new tools for assessment and
A simplified way to look for vitamin A: A new technique that
promises to be easier, cheaper and less invasive than blood
retinol analysis is dark adaptometry'. This method takes
advantage of the fact that in very early stages of vitamin A
deficiency, the ability of the pupil of the eye to constrict
under illumination is impaired. By flashing a simple
hand-held light at one pupil and covering the other, the
degree of impairment of the pupillary reflex can be
Dipsticks' for iodine deficiency: Since iodine excreted in
the urine is a good indicator of iodine consumed, iodine
deficiency disorders can be reliably detected by analysing
urine samples. A reagent-treated testing strip, or
dipstick', may soon be available that allows iodine content
of urine to be analysed and read directly on the spot without
transporting samples to a laboratory, saving time and money.
Improved test kits for iodized salt: Simple iodized salt test
kits have helped make salt-testing a community affair, but
the kits have a limited shelf life and do not distinguish
very sensitively among levels of salt iodization. Work is now
under way to improve the test kit in both these respects and
make it an even more useful assessment tool.
Computerizing anaemia surveys: Portable electronic
haemoglobinometers now enable blood to be drawn easily from a
finger into a small cuvette that is then inserted directly
into a machine. In a few seconds there is a digital read-out
of the precise haemoglobin level. These machines can help to
raise awareness of the enormous magnitude of the anaemia
New ways to enrich diets
Agricultural research is trying to develop staple food crops
that contain higher quantities of essential micronutrients -
or lower amounts of phytates, substances that impede the
bio-availability' of some important minerals.
The Consultative Group on International Agricultural
Research, made up of 17 internationally funded research
centres, is coordinating a global effort to increase the
micronutrient content of five major staple food crops: rice,
wheat, maize, beans and cassava. In developed countries, such
crops have already been produced: High-zinc wheat, for
example, is being grown in Australia. It will probably take 6
to 10 years to breed comparable new plants in developing
More effective action for nutrition improvement
The technical advances described in this report, whether new
research on nutrition and illness or better ways to detect
problems, are not magic bullets. They will contribute to
sustainable improvement in nutrition only if they sharpen the
ability of people, including poor people, to assess and
analyse the causes of malnutrition around them - and to plan
and carry out appropriate responses.
None of the preventive and supportive actions to promote
child growth and development described in this report
requires a doctor or nurse or a trained educator. Communities
can be helped to organize themselves to provide or administer
these services, and in most communities, groups that can take
on these responsibilities already exist.
It has often been said that meeting this challenge is a
matter of political will. In a $28 trillion global economy,
the problem is surely not a lack of resources. But it may be
more useful to see the challenge as a matter of political
choice. Governments in poor and rich countries alike may
choose to allow children to be intellectually disabled,
physically stunted and vulnerable to illness in childhood and
later life. This is the price of doing little or nothing to
ensure good nutrition.
But governments could instead resolve to move to consolidate
lessons already learned about reducing malnutrition. They
could do everything possible to mount massive actions that
can clearly succeed and that can be implemented by
communities themselves. And they could encourage research on,
and implementation of, new and better actions.
For the well-being and protection of children and the human
development of the world, the course of action is clear.
* * * *
Summing up malnutrition's shame
Higher child mortality
Directly or indirectly, malnutrition is associated in the
deaths of over 6 million children under five in the world
Impaired brain growth and development
* Iodine deficiency is the greatest cause of preventable
mental retardation in the world. Severe maternal iodine
deficiency causes deep and irreversible brain damage in
utero. Less serious deficiencies can lower a child's IQ by 10
* Iron deficiency anaemia during infancy and early
childhood can lower IQ by about 9 points.
* Low birthweight can reduce IQ by 5 points.
* Children who were severely stunted by the age of two
were found to have IQs that were 5 to 11 points lower than
those of children who were not stunted.
* One study showed that breastfed children generally had
IQs about 8 points higher than children who were bottlefed.
Higher maternal health risks
* Iron deficiency anaemia contributes to approximately 20
per cent of maternal deaths in Africa and Asia.
* In a recent trial in Nepal, vitamin A supplementation
reduced maternal mortality by 44 per cent.
Lifelong physical disabilities
* Folate deficiency induces neural-tube defects (spina
bifida) in newborns.
* Vitamin D deficiency results in poor bone formation,
* Stunting is associated with obstructed labour in women
and generally with increased mortality and lower physical
Malnutrition impairs the immune systems of at least 100
million young children and several million pregnant women,
none of them infected by HIV. Unlike the situation with AIDS,
the cure' for immune deficiency due to malnutrition has been
known for centuries: ensuring adequate dietary intake that
contains all essential nutrients.
Greater risk of chronic disease
Research indicates a link between malnutrition in early life
- including the period of foetal growth - and the development
later in life of chronic conditions such as heart disease,
diabetes and high blood pressure.
* * * *
* Malnutrition is a complex condition that can involve
multiple, overlapping deficiencies of protein, energy and
micronutrients - so called because they are nutrients needed
by the body in only tiny amounts. A child becomes
malnourished because of illness in combination with
inadequate food intake. Insufficient access to food, poor
health services, the lack of safe water and sanitation, and
inadequate child and maternal care are underlying causes.
* In as many as 35 of the poorest countries, 30-50 per
cent of the population may have no access to health services
* More than 1.1 billion people lack access to safe
drinking water and some 2.9 billion people lack access to
adequate sanitation. The result is the spread of infectious
diseases, including childhood diarrhoea, which in turn are
major causes of malnutrition. Each year, diarrhoeal
dehydration claims the lives of 2.2 million children under
five in developing countries.
* Inadequate care for children and women is an underlying
cause of malnutrition only recently recognized in all its
harmful ramifications. Good hygiene in and around the home
and in handling food reduces the risk of illness. Care also
includes all interaction between parent and child that helps
children develop emotionally as well as physically. Several
studies have found that malnourished children who were
stimulated verbally and cognitively had higher growth rates
than those who were not.
* Discrimination against women and girls is an important
basic cause of malnutrition. The very high rates of child
malnutrition and low birthweight throughout much of South
Asia are linked to such factors as women's poor access to
education and their low levels of participation in paid
employment, compared with other regions.
* Breastfeeding is the foundation of good nutrition for
infants, and inadequate breastfeeding can jeopardize infants'
health and nutrition, particularly in areas where sanitation
and hygiene are poor.
* In some industrialized countries, widening income
disparities, coupled with reductions in social protections,
are having worrying effects on the nutritional levels of
* Malnutrition contributes to over 6 million child deaths
each year, 55 per cent of the nearly 12 million deaths among
children under five in developing countries. Half of all
children under five years of age in South Asia and one third
of those in sub-Saharan Africa are malnourished.
* Malnutrition leads to reduced productivity, hampering
economic growth and the effectiveness of investments in
health and education, and deepening poverty. Vitamin and
mineral deficiencies are estimated to cost some countries the
equivalent of more than 5 per cent of their gross national
product in lost lives, disability and productivity.
* 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
* In the United States, researchers estimate that 13
million children, more than one fourth of all children under
the age of 12, have a difficult time getting all the food
they need. In the United Kingdom, children and adults in poor
families have been found to face increased risks due to poor
diet, including premature births, low birthweights, anaemia,
dental diseases, diabetes, obesity and hypertension. In the
Russian Federation, the prevalence of stunting among children
under two years of age increased from 9 per cent in 1992 to
15 per cent in 1994.
* Over 12,700 hospitals in 114 countries are now
baby-friendly, establishing a good start to breastfeeding for
millions of babies.
* Sixty per cent of all edible salt in the world is now
iodized, helping reduce the toll of iodine deficiency
disorders. Bolivia is the first and only country to certify
that iodine deficiency has been virtually eliminated as a
public health problem.
* In 1997 alone, the lives of at least 300,000 young
children were saved by vitamin A supplementation programmes
in developing countries.
* In Mbeya in Tanzania, a project improving health
coverage and access to safe water, as well as growth
monitoring and promotion, has produced a drop in moderate
malnutrition of 11 percentage points. In contrast,
malnutrition among children under five in areas not covered
by the project actually increased by 7 percentage points.
* In Brazil, the rate of malnutrition among children
covered by a community-volunteer growth monitoring and
promotion programme run by the Child Pastorate is half the
* In a village in Niger, malnutrition rates have fallen by
10 percentage points as a result of a programme that helps
women organize to reduce their workloads and enrich family
diets with new foods.
* Community volunteers in Oman's Al Dakhiliya region are
helping reduce child malnutrition through improved care and
* Nutrition promoters in Bangladesh are working in 1,000
community centres to help support breastfeeding and better
caring practices for women and children.
* Guatemala has brought vitamin A deficiency under control
by fortifying sugar with the vitamin. Sugar is also being
fortified with vitamin A in parts of Bolivia, Brazil, El
Salvador, Honduras and the Philippines.
* UNICEF supplied a total of 2.7 billion iron/folate
tablets to 122 countries between 1993 and 1996 for
distribution among pregnant women to help reduce iron
deficiency anaemia and folate deficiency. Wheat flour is
being fortified with iron in a number of countries in Latin
America and the Middle East.
* The nutrition of millions of children around the world
has benefited from improvements in health services,
particularly the achievement of immunization rates between 80
and 90 per cent in many countries.
* * * *
Micronutrients, so called because they are needed by the body
only in minute amounts, play leading roles in the production
of enzymes, hormones and other substances, helping to
regulate growth, activity, development and the functioning of
the immune and reproductive systems. Adequate intake is
especially crucial during early childhood and other periods
of rapid growth, pregnancy and breastfeeding.
The 1990 World Summit for Children singled out deficiencies
of three micronutrients - iron, iodine and vitamin A - as
being particularly common and of great concern for women and
children in developing countries. The Summit set goals for
the virtual elimination of iodine and vitamin A deficiencies
and the reduction of iron deficiency anaemia in women by one
third by the year 2000. Since then, knowledge of the
prevalence and importance of deficiencies of zinc and folate
have also been recognized. And more is being learned every
day about the importance of micronutrients for both the
physical and cognitive development of children.
* Iodine deficiency is the single most important cause of
preventable brain damage and mental retardation. In pregnant
women it significantly raises the risk of stillbirth and
miscarriage. There is also evidence that severe iodine
deficiency increases women's risk of pregnancy-related death.
* An estimated 43 million people worldwide suffer from
varying degrees of brain damage and physical impairment due
to iodine deficiency, including 11 million who are cretins,
afflicted with profound mental retardation. Some 760 million
people have goitres, the swelling of the thyroid gland in the
neck that is the most common and visible sign of iodine
* Less severe iodine deficiencies in children and adults
can mean a loss of 10 intelligence quotient (IQ) points and
can impair physical coordination.
* The successful global campaign to iodize all edible salt
is reducing the risk of iodine deficiency, which threatened
1.6 billion people as recently as 1992. About 12 million
infants born in 1996 were spared that risk thanks to iodized
salt, and the number of babies born cretins is estimated to
have dropped by more than half, from 120,000 in 1990 to under
* Over 100 million young children suffer from vitamin A
deficiency. It is a contributing factor in the 2.2 million
deaths each year from diarrhoea among children under five and
the nearly 1 million deaths from measles. Severe deficiency
can also cause irreversible corneal damage, leading to
partial or total blindness.
* Results of a dozen field trials in Brazil, Ghana, India,
Indonesia, Nepal and elsewhere indicate that supplementing
the diets of children at risk of vitamin A deficiency can
reduce deaths from diarrhoea. Four studies showed deaths were
reduced by 35-50 per cent. The vitamin can also reduce by
half the number of deaths due to measles.
* Vitamin A capsules cost roughly 2 cents each.
Supplementation reduces the risk of death of a child
deficient in vitamin A by 23 per cent. In 1997 alone, the
lives of at least 300,000 young children were saved by
vitamin A supplementation programmes in developing countries.
* Supplements of both vitamin A and zinc may boost
children's resistance to malaria, which kills 600,000 young
children each year, according to early evidence from a study
in Papua New Guinea. One third of children receiving vitamin
A had lower fevers due to mild to moderately high levels of
* Low-dose vitamin A supplements have been found to reduce
pregnancy-related deaths by an average of 44 per cent among
women in areas where deficiency is widespread, according to a
large-scale study in Nepal. The global toll of maternal
deaths is nearly 600,000 each year, the vast majority of
which are women in developing countries who die from largely
preventable causes. Yet scientists emphasize that high-dose
vitamin A supplements should never be taken by women of
childbearing age because of the potential risk of harm to a
* A 1994 study of HIV-infected women in Malawi concluded
that vitamin A-deficient women were four and a half times
more likely to pass on the virus to their children.
* Iron deficiency anaemia, the most common nutritional
disorder in the world, lowers resistance to disease and
weakens a child's learning ability and physical stamina. It
is a significant cause of maternal mortality, increasing the
risk of haemorrhage and infection during childbirth.
* Nearly 2 billion people are estimated to be anaemic and
millions more are iron deficient, the vast majority of them
women. A range of factors cause iron deficiency anaemia,
including inadequate diet, blood loss associated with
menstruation and parasitic infections such as hookworm.
* A single dose of antiworm medicine costs as little of 3
cents and can eliminate or significantly reduce intestinal
worm infections, an important cause of anaemia.
* Fortifying foods with iron and providing iron
supplements are two approaches to addressing iron deficiency.
Fortification of wheat flour and flour products is being
promoted, particularly in Latin America and the Middle East,
where these foods are widely consumed. UNICEF is a major
supplier of iron/folate tablets, providing a total of 2.7
billion for pregnant women in 122 countries from 1993 to
* Zinc promotes normal growth and development and is an
element in enzymes that work with red blood cells which move
carbon dioxide from tissues to lungs. It also helps maintain
an effective immune system. Zinc deficiency in malnourished
children contributes to growth failure and susceptibility to
infections, and is also thought to be associated with
complications of childbirth. There are, however, no data on
the prevalence of zinc deficiency. This deficiency usually
occurs where malnutrition is prevalent and is now recognized
as a public health problem in many countries.
* Trials in Bangladesh, India and Indonesia have shown
reductions of about one third in the duration and severity of
diarrhoea in children receiving zinc supplements and a median
12 per cent decline in the incidence of pneumonia.
* Zinc supplements helped blunt the most severe malaria
cases in children under age five, reducing by over a third
the number of such cases seen at health centres, according to
a study on zinc and vitamin A supplementation. Overall clinic
visits by those receiving zinc decreased by a third, and
signs of other infections were reduced by 20-50 per cent.
* The cost of a year's supply of zinc supplements for a
child is only $1.
* Zinc deficiency, increasingly recognized as widespread
among women in developing countries, is associated with long
labour, which increases the risk of maternal and infant
death. A number of studies have found that zinc
supplementation reduces complications of pregnancy.
* Folate is a B vitamin that helps in the formation of red
blood cells. Folate also regulates the nerve cells at the
embryonic and foetal stages of development, helping to
prevent serious neural-tube defects of the spinal cord and
* Folate deficiency causes birth defects in the developing
foetus during the earliest weeks of pregnancy - before most
women are aware that they are pregnant. It is also associated
with a high risk of pre-term delivery and low birthweight.
Folate deficiency also contributes to anaemia, especially in
pregnant and lactating women, and may be associated with
increased risk of maternal death and illness.
* UNICEF is a major supplier of iron/folate tablets for
pregnant women in developing countries, helping to reduce the
risks of folate deficiency for both mothers and infants.
* * * *
Child malnutrition and women's rights
In South Asia, where half of all children are underweight, 60
per cent of women themselves are underweight. In sub-Saharan
Africa, nearly one third of children are malnourished, and 20
per cent of women are underweight. About 24 million
low-birthweight babies are born every year, most of them in
developing countries. Their mothers are usually underweight
or overworked or were themselves stunted by inadequate
nutrition during their own childhood. These babies face a
greater risk of dying than heavier babies. If they survive,
they may face learning problems and they are also more likely
to become malnourished.
As these figures attest, the tragedy of childhood
malnutrition is rooted in part in the discrimination and
disempowerment so many women endure. What endangers women
endangers children too, according to The State of the World's
Children 1998 report, and full commitment to the rights of
women is one of the best ways of protecting children's
well-being and nutritional development.
To end childhood malnutrition, important questions must be
answered: Is a mother in good health? Was she educated as a
girl? Is she literate as a woman? How much of an effort has
her society made to convey essential information about
nutrition, diet, child care, personal and environmental
hygiene and the importance of breastfeeding? Do her family
and community relieve her of some of her burdens while she is
pregnant and breastfeeding, allowing her to get the rest she
needs? And is she afforded the same access as men to
education, employment and resources?
Sadly, the answer to these questions is often no, and the
discrimination and deprivation suffered by women becomes
their children's inheritance, all too often in the form of
malnutrition, illness and even death. The unequal
distribution of tasks and the disproportionate burden women
carry in households around the world makes them less able to
protect their own health and that of their children. For
example, a woman's ability to eat well and rest before and
during pregnancy is essential to both her health and that of
the developing child. But as one study in West Africa pointed
out, a woman who is pregnant even during off-peak
agricultural periods gains on average only 5.5 kilograms
during pregnancy, about half of the weight gain recommended
in most industrialized countries.
The oppression of women socially and culturally means they
have less access to everything, including food, resources,
health care, community support and information. The result is
that it is all but impossible for a mother to provide
high-quality child care, however much she loves her children,
if she herself is poor, illiterate, anaemic and unhealthy,
has neither safe water nor sanitation and lacks the support
of the father of her children and of her society as a whole.
Yet consistent and attentive care is the right of each child
and, if denied, perhaps one of the most significant factors
determining whether a child will be malnourished.
There is no single solution for the interrelated global
crises of the infringement of women's rights and child
malnutrition. The problems arise from cultural, political and
economic realities that must be addressed in tandem. However,
one crucial step on the road to change is to inform, to
educate and to challenge conventions that imprison women in
prejudices and poverty and thus contribute to the dire
problem of malnutrition.
There are important examples of where this has succeeded.
Nutrition, for example, has improved dramatically in
Thailand. Linked to a booming economy at that time, the
change has also been attributed to the fact that women are
respected in Thai society, enjoying high literacy rates and
playing a central role in the home and in the life of the
The war on childhood malnutrition must be fought on many
fronts. But, as is growing ever clearer, it will never be won
unless women's rights are assured, enabling women to play
their leading role.
* * * *
In Burundi camps, the spectre of malnutrition looms
Wrapped in a small green-and-yellow blanket, 16-month-old
Richard Nsabimana juts two tiny open palms into the air,
searching for his mother's arms. His hair is thin and white,
and his skin is broken, wrinkled and spotted with scabies. On
his legs, open sores invite a cluster of flies, and on his
foot, the squeeze of a thumb leaves an exceedingly prolonged
imprint. He is weak, has little appetite and is severely
It is a condition by no means uncommon in Burundi, where the
ghost of malnutrition has long since established itself in
hills and homes throughout the tiny Central African nation's
impoverished but verdant countryside, easily striking
children whose access to food, health, sanitation and proper
care is limited.
However, since the outbreak of civil war in 1993, levels of
malnutrition in Burundi have only increased, climbing ever
higher as the overall health situation deteriorates.
Conditions are the worst by far in makeshift camps for the
displaced. About 600,000 people - as many as 25 per cent of
whom are children - have been displaced inside Burundi during
the past five years. In some of the worst-hit areas,
particularly regroupment camps in Karuzi, rates of
malnutrition for children have reached 18.7 per cent, and
rates of severe malnutrition 4.9 per cent.
Malnutrition's causes are many and difficult to determine. "I
don't know why he's sick," says Richard's mother, 24-year-old
Madelene, cradling him in her arms. Richard has kwashiorkor,
and its causes are rooted in a combination of factors: part
diet, part health, part education, part access to food, part
care, and all amplified by the civil war.
Before the war, Richard's family cultivated a small plot of
land in the province of Karuzi, in central Burundi. The yield
was relatively abundant, and they were able to sell the
surplus of sweet potatoes, manioc and bananas in local
markets. "Before the crisis," says Madelene, "we had just
enough to make a good living." When civil war finally reached
their fields late last year and military authorities forced
them into a regroupment camp ostensibly for their own
protection - all that changed. Their access to their fields,
and therefore to their food, plummeted.
A month after entering the camp, Richard fell ill with
diarrhoea and intestinal worms. His parents are now sick as
well: his father with malaria; his mother, like him, with
scabies. The nearest health centre is 3 kilometres away, but
many times, Madelene says, they use traditional healers
Their diet consists primarily of beans, porridge and
supplementary food from an NGO. But, she says, "it is not
enough." Like many families in Karuzi, they have been unable
to cultivate their fields, partly due to sickness, partly to
restrictions placed on their movement by authorities. And
when Madelene is able to go back to her fields 2 km away, she
gathers whatever food she can for her family. But, she says,
"whatever is there is there by the grace of God."
The atmosphere in this camp, like in many others, has
aggravated and compromised the nutritional status of the
children of Burundi. Richard Nsabimana, unfortunately, is not
* * * *
Malnutrition in industrialized countries
Supermarkets stock fresh fruit and vegetables in the middle
of winter. Meats and canned and processed goods of all sorts
line the aisles. Food is abundant and readily available in
most industrialized countries. As a result, the general
feeling is that whatever problems industrialized countries
may have, malnutrition is surely not one of them.
Yet, readily available and sufficient food does not
automatically bring about good nutrition. On the contrary,
obesity is one major nutrition-related problem in the United
States. According to the most recent government statistics,
over half the American population today is obese, and of
children between the ages of 6 and 17, nearly one fourth are
Obesity carries with it increased general health risks,
including a higher incidence of cardiovascular disease,
hypertension, non-insulin dependent diabetes, certain kinds
of cancer, gall bladder disease, menstrual abnormalities and
complications of arthritis and gout.
Obese children face traumatic social and psychological
difficulties and increased risk for high blood pressure, high
blood cholesterol, abnormal glucose tolerance and possible
orthopaedic problems, such as difficulty with walking. Obese
children tend to become obese adolescents, who tend to become
A number of factors bring about this disorder and can
interact with one another. Besides nutrition, both genetic
make-up and cultural behaviour patterns can predispose a
person to obesity. Endocrinological and metabolical factors
are also involved.
A long-time researcher in the field, Dr. William H. Dietz,
noting the increased frequency with which, paradoxically,
both hunger and obesity occur in poorer populations in the
United States, has suggested that one cause of obesity might
well be hunger.
Without question, the poor in the United States do suffer
episodic food insufficiency'. One recent study concluded
that there are more than 13 million poor children under the
age of 12 in the United States who are hungry, or at risk of
being hungry, during some part of one or more months of the
Clear signs of nutrient deficiencies have also emerged,
according to one recent study, among one- to five-year-olds
in poor families as well as in those better off. Defining
deficiency as receiving less than 70 per cent of the
recommended daily allowance of the 16 standard nutrients
measured in the survey, the study found that 6 per cent of
one- to five-year-olds from families not considered poor did
not receive enough food energy, folate or vitamin C. Over 15
per cent did not receive enough calcium and nearly 20 per
cent not enough vitamin E. Fully one quarter did not get
enough iron, and over a third failed to receive enough zinc.
For poor children, the findings were even more disheartening:
Substantially higher proportions were deficient in 14 of the
16 nutrients. For example, in 40 per cent of poor children
iron intake was inadequate, and 18 per cent received
inadequate vitamin C.
The very abundance and availability of the wrong kinds of
food, eaten with little moderation or balance, is another
culprit. Nutritionally deficient foods such as soft drinks,
chips, candy and fast foods tend to crowd out nutritionally
And the increasingly sedentary pattern of life in the modern
industrialized world is yet another suspect. A study
published last year found that 10- to 15-year-olds who
watched more than five hours of television a day were 4.6
times more likely to be overweight than youngsters who
watched two hours or less.
Other industrialized countries show similar patterns,
particularly among less well-off groups. One British study
describes the diet of lower socio-economic groups as
providing simply "cheap energy," comprising mainly foods such
as full cream milk, fat, sugars, jams, potatoes, cereals and
meat products. The diet includes few vegetables, fruit or
wholewheat bread and is low in essential nutrients: calcium,
iron, magnesium, vitamin C and folate. The study also shows a
correlation between the diet and poor health.
In France, recent reports say that the poorest people spend
over one fourth of their income on food, yet what they buy is
similar to the inadequate diet of the British poor: bread and
other starches, coffee, milk, sugar, processed meats and
hardly any fruit or vegetables. Not surprisingly, a field
study of one of the poorer suburbs of Paris found that the
children who lived there were at risk nutritionally.
Significantly, a study of newborns in France found that fully
63 per cent showed iron deficiency and 55 per cent suffered
Ways need to be found to change these nutritional patterns
since plentiful food alone is clearly not a solution. Taking
care - in what is eaten and when - is as necessary a step in
industrialized countries as it is in the developing world.
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