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The Himalayas' Hidden Hunger

In a nation of farmers, undernutrition leaves children stunted and at lifelong risk. Can a novel study help save Nepal's next generation?

Story and Photo by Cathy Shufro

School has let out for the day in the Himalayan hill town of Sitapur.

Children in blue-and-white uniforms flood out of the school courtyard onto the only road running through this town in midwestern Nepal. A boy runs joyously, his backpack bouncing. A girl with black braids leads her little brother up the steep path to the neighboring village. A few boys send a volleyball back and forth over a net strung to a house. The children's voices overlay the faint shouts of men calling to their oxen in emerald rice fields in the valley far below.

These schoolchildren look like kids anywhere exulting in release from the classroom. But on this July afternoon, their familiar exuberance deceives. It's likely that nearly half these children have already suffered irreparable harm.

The cause is chronic malnutrition.

Some 41 percent of Nepali children under 5 are moderately or severely stunted, according to Nepal's 2011 national health survey. Long-term undernutrition coupled with recurrent infections and other consequences of poverty has caused them to be stunted-that is, markedly shorter than well-nourished children of the same age. Short stature is only the outward manifestation of how malnutrition damages children. Long-standing undernutrition thwarts the development of their brains and bodies, undermining their chances to prosper as adults.

There's no reason to think that the children of Sitapur have fared any better.

Hunger in a Nation of Farms

Nepal's slow progress against stunting contrasts with other health advances. The country cut both child and maternal mortality in half in the past 10 years despite ranking 157th out of 187 countries in the UN Human Development Index, and despite enduring a decade of political upheaval that only ended in 2006. This nation of 30 million also is a global model for preventing child deaths and blindness by giving vitamin A supplements to preschool children.

So why has undernutrition proved so intractable here? Why aren't people well fed in a country where 70 percent of the workforce is engaged in farming-in growing food?

To answer that question, researchers from the Bloomberg School and Tufts University's Friedman School of Nutrition have launched an ambitious nationwide study that pays attention not only to diet but also to a broad range of other factors that influence nourishment, including agriculture.

In May 2013, 66 interviewers and 30 supervisors and research assistants completed the first of three annual surveys. In 60 representative towns and villages and three neighborhoods in the Nepali capital of Kathmandu, interviewers talked to any woman who had a child under 5 or who had recently married. They also interviewed the head of each woman's household (generally her husband or father-in-law).

In 4,288 households across Nepal, interviewers asked a broad range of questions about factors that can affect nutrition for young children and their pregnant or nursing mothers: what children and their mothers eat, and whether they have enough; which foods families grow, and which they buy. When an interviewer asked, for instance, how much rice a mother and her children under 5 ate during the past week, the interviewer also asked if the household grew rice, if they owned the land where it was grown, and whether they ever got so hungry that they ate seeds intended for planting the next crop.

The survey teams raced to finish data collection before the midsummer monsoons made travel difficult. They visited communities in all three ecological zones-in the southern plains near the Indian border, in small towns in the hills (including Sitapur) and in high-altitude villages near Mount Everest-one of them was a five-day trek from the nearest road.

"It's a little breathtaking," says Keith West, DrPH '86, MPH '79, RD, director of the Bloomberg School's Center for Human Nutrition. West is the School's principal investigator for the study, called PoSHAN, an acronym that means "good nutrition" in Nepali. The $15 million, five-year USAID grant is led by PoSHAN principal investigator Patrick Webb, PhD, of Tufts.

The aim of the Bloomberg School's team is to apply public health methodologies to mapping the complex interactions between nourishment and what's grown, what's eaten and what efforts have been made to improve nutrition, health and farming. The Tufts team, meanwhile, is analyzing how well policies and programs for improving agriculture and nutrition translate into action as they move from Kathmandu to towns and villages.

The interdisciplinary focus of the research makes the study unusual, according to West. "There's a deep sense that agriculture and nutrition have not talked to each other over the decades, and the centuries," he says.

Governments, nonprofits and community groups have repeatedly tried to address malnutrition by improving farming. And yet no one really knows what, if anything, has worked. When Webb and a colleague studied 10 reviews that had closely examined 250 of the strongest studies, they found all 10 reviews concluded that the studies provided little or no evidence that agricultural interventions improve nutrition. The reviewers found that most of the studies were badly designed or poorly analyzed.

"There are decades of claims that say, 'Do this, and we'll improve nutrition,' but actually very, very few studies have succeeded in documenting it," says Webb. "It's astonishing."

The stakes are high. Globally, undernutrition means death for 3.1 million children younger than 5 every year. It caused 45 percent of all child deaths in 2011.

Yet the factors affecting nutrition are numerous and difficult to isolate. For instance, a family might provide more protein for their children if they raised chickens. But that gain would be undermined if chicken droppings caused recurrent diarrhea in the children. Or, consider a family that chose to raise poultry rather than plant a garden. They would not have their own vegetables to eat but they might make enough money by selling eggs or meat to buy a mobile phone that would make a family business more competitive, increase income and allow them to buy vegetables. The linkages are complex.

With this study, says West, "we're embracing the complexity."

Shorter Stature, Shorter Lives

By September 2013, piles of completed surveys were stacked, waist-high, in an office in Kathmandu. There, Bloomberg School project scientist Swetha Manohar, MSPH '11, RD, and colleagues had begun analyzing the data.

In part, they were looking for stunting. Everywhere they'd gone, the survey teams had weighed and measured children, and those numbers would show the prevalence of stunting.

Stunting signals trouble: It results from poor nutrition over the long term, not just small setbacks caused by a recent food shortage or a child's transient illness. Stunting embodies chronic gaps between nutrition and agriculture. It is also important because it costs a child so much. For children who survive, the deprivations and insults that cause stunting not only hinder physical and intellectual development but also increase the lifetime risk of degenerative diseases and, ironically, of being overweight; genes are made "thriftier" by long-standing privation so that the body maximizes fat storage.

The 1,000 days that begin with conception are the most crucial: By age 2, stunting is largely irreversible. After that age, children can't catch up, says International Health Professor Robert E. Black, MD, MPH, a veteran health and nutrition researcher who directs the Institute for International Programs.

And stunting is insidious. In societies where stunting is pervasive, it may go unnoticed, says Black, adding "everyone looks small, so it looks normal. It's the usual pattern of growth." Though it may appear to be the norm, it substantially increases the risk of death. Nearly 15 percent of under-5 deaths stem from stunting.

Damage can begin at conception if the mother herself is stunted or underweight. She is more likely to give birth to a baby that is small for its gestational age. Restricted fetal growth accounts for 20 percent of stunting worldwide. If a stunted child is a girl, she will be more likely to give birth, in turn, to an underweight baby.

"It's an intergenerational issue," says Manohar.

Although stunting has declined worldwide by one-third since 1990, it still affected 165 million children in 2011, 69 million of them living in south-central Asia. The individual impairments that stunting causes, multiplied by these millions, affect national economies: pervasive stunting in a population reduces gross domestic product by an estimated 8 percent.

"Stunting is a reflection of loss in human capital," says Keith West. "And that human capital develops early in life. So preventing stunting is a metaphor for improving capacity."

Finding the Right Kernels

Sabina Maharjan is out of breath when she arrives at a sturdy stone-and-mud house on a narrow terrace high above Sitapur. She has been climbing for half an hour to reach this place, one of 38 scattered homesteads that make up the roadless village of Durkatta. Maharjan has scheduled this interview for early on this summer morning, before the family's workday has begun in earnest.

She greets the head of the household, a relatively prosperous farmer in his mid-40s. He and his wife have four children. Maharjan perches on a shaded wooden veranda in front of the two-story house, and the man faces her on a woven bamboo stool. Maharjan asks him the first in a series of questions and follow-up questions that will require two hours to complete. Does he own this house? Does it have electricity? How many fans are in the house? Radios? Bicycles?

She marks answers on a form fastened to a clipboard.

How does the family treat its water: simply allowing sediment to settle, boiling, adding chlorine? Who fetches the water, and how long does that take? Where do children under 5 defecate? In a household toilet, outdoors near the house, in an open field, in a river? Do animals live inside the house?

After answering a few questions, the man darts inside the house and returns with a topi, a traditional cloth hat commonly worn by older Nepali men. Donning the hat suggests that he takes the interview seriously, but he laughs as he does so, making fun of his own self-consciousness.

A few minutes later, his older son appears at the top of the trail, bent over, a tumpline across his forehead to support the weight of the grasses he's cut for the family's two water buffalos. By this time, Maharjan is asking a long series of questions about farming: Which of 22 crops does the family grow during the wet season? And which ones during the dry season? What crops did they eat themselves, and what did they sell? She asks which animals they keep, from bees to pigeons to pigs. She asks if they vaccinated their buffalos.

To do this job, Maharjan attended six weeks of training in Kathmandu. All 66 "enumerators" were women because of the intimate questions they would ask mothers and mothers-to-be. Each trainee had to master a 180-page manual.

"There was a lot to digest," says Swetha Manohar, who oversaw the training. "She has to understand what crop rotation is, but she also needs to know what a micronutrient supplement is. She has to know what contour lateral irrigation is, versus pipe-based irrigation."

Maharjan and the others also had to learn how to standardize data so similar responses given to interviewers in the mountains and the plains would be marked the same. For instance, how would "two oxen can plow my land" translate into hectares? If a girl was promised to a man at age 12 but moved in with him at 18, how long has she been married?

Choosing survey questions required restraint. For the people interviewed, taking several hours to answer questions is, as West puts it, "expensive." Participants lose time from gathering wood, mending roofs, cutting fodder. Even in urban Kathmandu, many people have to fetch water from rivers or haul it up from wells. "The poor don't have time," says West, "so we've spent a lot of time to find the kernels of information that are probably important."

Maharjan is asking about household finances when the man's teenage daughter brings out rice with milk, breakfast for her 4-year-old brother and a visiting child. The boys attack the rice, then tip up their bowls and contentedly slurp the milk. A typical meal in Nepal consists of a mound of rice and a dish of dal (lentil gravy), and perhaps a few tablespoons of vegetable curry. The diet tends to be low in micronutrients and in protein.

By the time Maharjan asks her last question, it's mid-morning. She will return the following day to interview the man's wife, who has by now departed for the rice fields. Maharjan will record what the woman has eaten in the past week, ticking off a list of 49 foods that begins with rice and ends with Wai-Wai, packaged fried noodles that are popular in Nepal. She will ask how much the woman knows about keeping children healthy. What would she feed a child who was sick? When should she wash her hands? Maharjan will also ask about the woman's power within the family. Who decides whether to use contraception? Who decides when the woman can visit her mother?

Then Maharjan will weigh and measure the woman and her 4-year-old son. If the mother was randomly selected to give a blood sample, to measure hemoglobin, Maharjan will take a few drops.

No Time to Waste

Enumerators will return to Sitapur and the other 62 communities in spring 2014 and again in spring 2015. To track seasonal fluctuations in nutrition, they will also conduct surveys each September (after the monsoons) and each January in three representative "sentinel" communities-one in the mountains, one in the plains and one in the hills (in Sitapur, in fact).

For Sitapur and other hill communities, preliminary results are in: 36 percent of children under 5 are moderately or severely stunted. That's slightly better than the national average of 41 percent.

Analyzing the data further will allow the PoSHAN researchers to look for associations between good nutrition and the many factors that affect it. For instance, perhaps the surveys will show that families have fewer stunted children if they build toilets or have cleaner sources of drinking water. Perhaps it will show that one program promoting hygiene and sanitation was associated with improved nutrition, while another was not.

"We get at least a snapshot of these kinds of patterns," says West, " and returning next spring to the same homes will give us a longer-term view. This will help us find ways to guide programs toward greater impact, to favor the good influences while always trying to lower costs."

Nepal's Ministry of Health would value that kind of recommendation, says Raj Kumar Pokharel, MPH, chief of the child nutrition section. "Experts come and give ideas, for example, small fish farming or a sweet potato hybrid," says Pokharel. "Some say, 'Oh, golden rice is a very good source of vitamin A and micronutrients.' We don't know what to adopt. … The agricultural sector wants to increase productivity and variety. But it's dietary diversity within the household that we want to cultivate."

That applies to both the poor and the (relatively) rich: Not only were 81 percent of Nepal's poorest children stunted in 2011, but so were 32 percent of the richest. Pokharel blames poor nutrition partly on fast foods like the instant noodles whose bright packages occupy the front racks in urban food shops and village markets alike. He likens noodle manufacturers to American tobacco companies because they are pushing harmful products, "deteriorating the health status of our children."

Pokharel looks forward to finding out what the PoSHAN household surveys show about what people actually eat, day to day. The government will use that information to advocate for crops that will support or improve diets in the various ecological zones, and to fine-tune programs that educate people about what to grow and what to eat. Declines in stunting will signal success.

There's no time to waste, says Pokharel. Nepal did manage to reduce stunting by 8 percentage points between 2006 and 2011. But at that rate, it will take a generation to bring it below 5 percent.

"Stunting reduces IQ levels and the capacity of the brain," says Pokharel. "If you can calculate it in terms of daily losses, in terms of how much we are losing every day, every minute, every month and every year, we cannot wait."