This week I had the great pleasure of working with a distinguished international civil servant, public policy expert and peace advocate: Kul Gautam. A man with a long career in international development having served as the Deputy Executive Director of UNICEF and Assistant Secretary-General of the United Nations.
Kul joined us this week for our Nutrition Advocacy Tour. Over the last few days our guests, Kul Gautam and Walter Nyika, have met with various MPs, representatives from the media and RESULTS UK’s dedicated grassroots groups with the aim of raising the profile of nutrition ahead of the Prime Ministers Hunger Summit ‘Nutrition For Growth’ in June.
I had the opportunity to sit down with Kul and find our more about nutrition in Nepal.
A country of contrast
“This is a land of contrast.” Kul is talking about Nepal. The country where he grew up and now resides with his family. “[It] is a country with one of the highest burdens of malnutrition. It is one of the least developed countries, with very low per capita income. It is a country that has been in war, civil war, for 10 years… but surprisingly Nepal is making pretty good progress.”
In fact Nepal is on target to reach many of the Millennium Development Goals (MDGs), particularly MDG 4 – to reduce child mortality rates.
“If you look at stunting Nepal is one of the few success stories. Stunting has gone down from 57%, ten years ago, to 41%. Forty-one percent is still too high. But it is going down and that is significant for a country that has been in a period of flux, transition and civil war.”
“And you might ask ‘how could that happen?’ When poverty is so high, when there is political instability and when economic growth is very poor.” Kul credits Nepal’s success in this area to 50,000 female community health volunteers (FCHV). Recognising the that for many people care happens in the home by family or community based caregiver, Nepal has focused on teaching health workers the importance of things such as breastfeeding, micronutrient supplementation and anti-natal check ups, and then having them spread the word throughout their communities. These community health workers, the majority of them volunteers, are fundamental in build partnerships and linkages with sometimes overburdened health services.
“Today in Nepal, if you look at vitamin A coverage it is as high as 95%, consistently for a decade… Nepal’s [vitamin A] coverage is one of the highest in the world, largely thank to these female community health workers and their outreach. They do amazing things.”
A micronutrient masterpiece
Nepal’s micronutrient success is not exclusive to their Vitamin A coverage.
“When I was a child, in my village and wherever I went, I always saw lot of people with this big goitre; this huge bulge on their neck. And that was so common that we took it for granted that, yes, you get this thing and okay it’s a little inconvenient, it’s ugly, but it’s the way it is. [But] today, you don’t see any.”
Women suffering from goitre
“We have made tremendous progress to ensure all the salt consumed in Nepal is iodized." This is very interesting considering Nepal is a landlocked country. "We don’t have access to the sea and we don’t produce any salt... [In fact] all the salt in Nepal comes from India. Yet, Nepal has a higher rate of converge of iodized salt than India." Kul credits the this success to the progressive action of the countries health leaders.
“We used to think, as a child, that it was just an ugly bulge, but is has far more repercussions on the intellectual development on children. It is the world’s most widespread cause on mental disability, lower IQ and lower ability to learn in school. So once we solved that problem, many other problems have been solved. Not only in health and nutrition, but in education.”
Nutrition is not just about food
Many people still believe the cause of undernutrition is ‘not enough food’, or ‘not enough balanced diet’, or ‘not enough variety of food’. So for many people the answer is to invest in agriculture. But Kul warns that this is "too simplistic." In fact the causes and impact of undernutrition vary from country to country.
In 1995 UNICEF commissioned a study, 'The Asian Enigma', to examine why rates of malnutrition were twice as high in south Asia than in sub-Saharan Africa. At the time people could not understand why undernutrition was so much higher in Asia than in Africa. "In Africa you have had civil war, you have had drought, plague, HIV... every problem imaginable... Therefore, you would think Africa would be worse off that South Asia. [But] that is not so. [In fact] South Asia has double the rates of malnutrition."
"We found two reasons. One was the role and status of women. Women were better treated in Africa than in South Asia. A baby girl is not as well treated as a baby boy. She grows up malnourished. She doesn’t perform so well in school. As an adult she may be a low birth weight mother. And the cycle continues."
"So the strategy in Nepal, and South Asia, had to be something about the role and status of women. That may not sound like a nutrition activity but it actually had huge nutrition impact."
When talking about some of the developments in Nepal, Kul cited women's empowerment as the most positive development. "We still have many illiterate women, but even the illiterate women are conscious of their rights. When you go to meet with women’s groups... they are vocal, they are very eloquent, and they are articulate.”
The second reason the study identified was sanitation. This is an area, Kul says, that "we are still not doing a good enough job."
"Asia is more densely populated than Africa. Africa is a vast continent, with a relatively small population. So most of Africa is rural. In Asia the population density is much higher and the sanitation is much poorer. And so much of malnutrition, in Nepal and South Asia, is because of hygiene and sanitation. If hygiene and sanitation is poor it can cause infection. Infection leads to malnutrition."
"Today many households will have mobile phones, even electricity, but no toilets.”
The SUN Movement
“I think the SUN [Scaling Up Nutrition] movement has been the greatest new initiative in the field of nutrition in a long while."
Kul points out that many of the problems of undernutrition - stunting and wasting - that we are talking about today were well known 20 years ago. But the problem was that there was no consensus.
"The biggest contribution of SUN is that is represents a consensus that we have been longing for many decades. It is an approach, for me, that is very practical. It talks about the costs, the nutrition specific and nutrition sensitive areas of work, it talks about the need of a multisectoral approach to talking malnutrition. One sector or approach alone cannot do it. SUN is a great breakthrough in malnutrition."
Nutrition and broader development
The major barrier we have, which needs to be tackled, is to ensure undernutrition is actually recognised as important, not only for nutrition, but for broader health, social and economic development.
"Malnutrition is a cause, not just a consequence of poverty. That realisation needs to be there... [O]nce our leaders truly recognise that malnutrition is the mother of all problems, that it is the root of many issues, then, I think, nutrition will get the kinds of resources and priorities that it deserves."
The case of Nepal shows that even very poor countries can make quite dramatic progress against undernutrition.