At the age of four, Henintsoa Rakotoarimanana weighs just 10kg and, at a height of 84cm, is not much larger than a baby. Fed on rice and cassava since he was born, he is now receiving treatment for malnutrition at Maharodaza Nutrition Centre in Manjakandriana, about 30km from Madagascar’s capital, Antananarivo.
Part of this treatment involves training his mother, Juliette Raharimanana, on how to prepare the right foods for her child. “I will try to make the yams into soup, so it’s softer. Maybe that will help him to gain weight,” she said, adding that Henintsoa does not like to eat fruit and vegetables.
“We teach these mothers that children need to eat from the three different food groups, but it’s difficult to change their habits,” Niaina Andrianjatovo, an instructor at the centre, told IRIN. “Sometimes, they’ll follow our instructions for a while, but then they go back to their own ways. So we have to repeat the same message over and over.”
The result of under-nourished babies is children and adults who never grow to their full potential. Children who are stunted are at greater risk of illness and death and impaired cognitive development, while a 2006 World Bank study found that stunted adults earn 10 percent less over the course of a lifetime.
A report on child malnutrition released this month by Save the Children UK puts the number of children affected by stunting globally at 170 million, and notes that if current global trends such as volatile food prices, climate change and economic uncertainty continue, more than 450 million children will be affected by stunting in the next 15 years.
The Madagascar Demographic Health Survey 2008-09 found that stunting affects half of all Malagasy children under five, the sixth highest rate of stunting in the world, according to the UN Children’s Fund (UNICEF). The problem is especially prevalent in the central highlands region around Antananarivo.
Poverty is a major factor, particularly more than two years into a political and economic crisis that began with Andry Rajoelina's ousting of President Marc Ravalomanana in 2009 and the withdrawal of all but emergency donor aid to the country. The Southern Africa Regional Food Security Update for February 2012 notes that four-fifths of Madagascar's population now lives on less than US$1 a day and poor households spend 74 percent of their income on food.
But the country's high rates of stunting also have much to do with the Malagasy obsession with rice. Although many children consume enough calories, they have trouble growing because their diet consists almost exclusively of rice, to which cassava or a salty soup may be added and, if the family has enough money, some fatty meat. “We found that the highest occurrence of stunting is not among the very poor, as they eat the vegetables that they grow instead of selling them, and these are rich in nutrients. The worst cases are those who can afford white rice,” said UNICEF nutrition expert Amal Bennaim.
Rice is not the only culprit. At the Nandihizana Nutrition Centre, also in Manjakandriana, community worker Saline Rasoazanamanana battles all kinds of harmful feeding practices. “We tell women to exclusively breastfeed for the first six months, but they often feel they don’t have enough breast milk. So then they give the babies tea or coffee as a supplement,” she said.
Andrianjatovo noted that some mothers simply do not feed their children enough. “During the day, the mothers are busy working in the field. The children just play around the village. Sometimes the mothers will leave some yams with a caretaker to feed the children at noon, but often they get no food at all until night time. This is especially a problem with breastfed babies - they need to drink eight times a day, but often only get fed two or three times.”
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High rates of infection during pregnancy and childhood also contribute to stunting in Madagascar where 8 percent of children under five suffer from diarrhoea, and pneumonia affects 3 percent.
The whole discussion about stunting is quite new in Madagascar, said Bennaim. “People used to think being short was genetic, but then they discovered that well-nourished babies and young children fall within the same height range anywhere in the world. It’s only during the teenage growth spurt that genetic factors about height kick in.”
The most critical period for stunting is from conception until a child reaches two years, but in Madagascar, the problem does not stop in early childhood.
Poor nutrition means that girls often do not reach their full growth potential until they are 21, by which time many are already mothers. About 39 percent of Malagasy women measure under 150cm in height and are more likely to have low birth weight babies. “Pregnancy in teenagers stops the girls’ growth completely. This in turn leads to low weight babies, so there’s a vicious circle we have to break,” Bennaim told IRIN.
In the past 20 years, Madagascar’s National Nutrition Office has set up 5,550 community nutrition sites, where babies are weighed monthly and mothers receive information about child feeding. The Nandihizana centre alone is visited by 200 mothers with over 300 children under five every month. Community workers at the centre teach mothers how to grow fruit and vegetables that can be added to their children's diet at little cost. “I’ve seen how they changed. You can see that the children become stronger and won’t get sick so easily,” said community worker Rasoazanamanana.