The Global Cost of Childhood Malnutrition

[Brian Hanson: INTRO: This is Deep Dish on Global Affairs going beyond the headlines on critical global issues. I'm your host Brian Hanson with the Chicago Council on Global Affairs.

Ten years ago, our guest, Roger Thurow, started working on a book called “The First Thousand Days”, where he followed mothers and their children to see how proper nutrition during the first thousand days of a child's life can profoundly influence an individual's ability to grow, learn, and work.

Today, he takes us on a journey back through India, Uganda, and Guatemala, where he provides updates on the moms and children featured in his book. These children are now nine years old, and we'll discuss the impact of good nutrition on growth and development. In a spoiler alert, in a world in which there's certainly is too much suffering and too much bad news, this is a story of hope, of things getting better -- slowly, too slowly, but progress is occurring and with sustained effort, many million more lives can be transformed and improved.

Here with me is Roger Thurow, a senior fellow on Global Food and Agriculture here at the Chicago Council on Global Affairs. He's the author of the book, “The First Thousand Days, A Crucial Time for Mothers and Children and The World”. Previously, Roger was a foreign correspondent for the Wall Street Journal for many years.

And I wanted to start our conversation by asking Roger to explain what the first thousand days means and why it's so important…]

Roger Thurow: So the first thousand days is the time through pregnancy. So when a mom first becomes pregnant, Through to the second birthday of the child, and it's about a thousand days, it is a part of all of our lives. It's something that, that everybody goes through. So it, it's crucial. Because in that first thousand days, that is setting the foundation for the physical growth and the healthiness of a person. The cognitive development, because so many things are going on in the development of the brain and kind of the, all the neural synapses that are happening, and Brian, so all the executive skills that we use every second of the day. So as we're using on this podcast and all the listeners listening to it, interpret, to analyze, to feel, to sympathize, that's all forming during the thousand day period and particularly already, cresting even in some instances in the cognitive development before the child is even born. And so that's why nutrition is so important in that period because nutrition provides fuel for the physical growth, the cognitive development, strengthen the body against diseases throughout life, and then particularly chronic diseases. So it's this fundamental period that's important, not only that for the individual and the family, but for all of us. 

Brian Hanson: And what happens if a child is, if a mother, when pregnant and a child in this period of time doesn't get the nutrition that's needed?

Roger Thurow: Either because they might be in a, acute hunger situation -- so there's a shortage of food, there's a famine, there's a drought, whatever has triggered that. And we see so many instances in our world today, lamentably, that's still a part of our world, or kind of any longer term chronic lack of access to not only food, but for the nutrients, as well. So it's not just calories that provide kind of enough daily energy for us, but then also the nutrients. And so this micronutrient deficiency then becomes so important and what the impact of that is kind of any prolonged exposure to that or suffering from that leads to stunting and the medical, the scientific academic definition of stunting is too short for age,

Brian Hanson: In terms of a person's height..

Roger Thurow: Yes.

Brian Hanson: growing.

Roger Thurow: Yeah, precisely. So eventually there's hereditary factors that come into that, you know, as the child and the person grows. But what I found in this, and then what so many people were telling me about is that, you know, yeah, that might be the, outward manifestation that you can see, what's particularly critical then is the cognitive stunting and the, slow down or interference with the development of, as I said, these neuro skills the workforce studies show that, they might earn then 20 to 40% less, than well-nourished children or children that weren't, suffering from childhood malnutrition and stunting. and then the greater incidents, of chronic diseases as they go through life. So that's this life sentence of underachievement and underperformance.

Brian Hanson: And how widespread is this problem? How many people are we talking about that experience this?

Roger Thurow: So my mantra as a journalist is to outrage and inspire. And so, all my books and my writing, even at the time at the Wall Street Journal, there'd be kind of a central outrage and then the inspiration as you talked about kind of the good news and the hope that comes from this. But the outrage is that basically, still one in every four children under five years old in our world today is stunted in some manner in 2023. So, 23 years in this grand new millennium of ours in the 21st century. Still. So, the ones who do this counting into calculations is about 22, 20 3%. it's risen again, during, covid, during all the, then, climate change interruptions on farming, the availability of nutrients, what we're seeing in Ukraine and everything that the, the, impact that has had on the global food chain. So when you think about that, it's one in every four basically of children under five.

Brian Hanson: Yeah.

Roger Thurow: Because we see the impact of that. So the impact, it's like, throw a stone or a pebble into a pond and it hits the placid surface and all these ripples that form, right? And so the initial ripples obvious are the individual, and we talked about kind of the impact of that through their life. next impact would be the family. if there's one stunted, malnourished, stunted child, there's probably more, in the family that will impact earnings of the family throughout life. As we talked about the healthcare cost are more, then the impact on the community, because the labor force, the productivity, the collective, the communal healthcare cost, that are all associated with that, you know, then to like the country or the entire, continent like in Africa where it might be like a third of all children than are stunted a country like India, you know, that we associated with such progress and the technological wonders and whizzes that are coming out of, India Still. third of the children, are malnourished there. And again, they carry that through life. So, the World Bank has calculated and others that are looking at this on economic front, that the cumulative impact of childhood malnutrition and stunting, is an annual cost of about three and a half trillion a year. That's not a one-time cost. It is every year cumulative, ongoing, cuz again, stunted children become stunted adults. They carry this overtime. It becomes a generational, aspect that say, girls that are malnourished, from birth or early in life. when they become moms, they may also then still be struggling with malnutrition that'll then be passed on to their children that may have low birth weight and struggling with nutrition. So you can see how that then spins through time. It's the opportunity cost that when you look at what might a child have accomplished for all of us, were they not malnourished and stunted, particularly in these first thousand days? And that's like a poem, not written, a song not sung, a novel, not imagined, a horizon not explored, a gadget not invented, a cure not discovered, what are we missing? when you look at it, this lost chance of greatness, then for any one child, because of this life sentence of underachievement and under production, this lost chance of greatness for any child then becomes a lost chance of greatness for us all. 

Brian Hanson: It's just such a compelling and urgent picture that you just painted of the nature of the challenge and in the book, and in your research, you identify and follow, families and children, who are going through the first thousand days, and then subsequently you've continued to keep in touch. As I mentioned, they're now nine years old. Can you talk about some of the things that were done, to provide opportunities for the children and mothers that you followed to get the nutrition that they needed in the first thousand days? And then, share with us some stories of what happened as a result of that access to nutrition.

Roger Thurow: So, my first challenge of this as a journalist and figured, okay, so how do I write about the first thousand days? I figured, well, I should probably follow some moms and children through the first thousand days. My previous book, “The Last Hunger Season”, I had followed farmers in Kenya through the course of a year. So I figured, ah, so a thousand days, I can do that. But when you're kind of observing people over time and going back and back and back and to visit them, then it's like, wow, this is a long period. Um, so nearly three years and so followed moms and their children in, India, Uganda, Guatemala and Chicago. And Chicago, basically to say, yeah, again, it's not a problem just over there, it’s something that impacts all of us and it's all around us. So, no matter where we are in the world, and particularly the importance of good nutrition, that's like humanity's common denominator. We all need that. You know, nobody's too rich or too poor or, greatly educated or illiterate or Republican or Democrat, we all need this, right? So that's our common denominator. So that's why I wanted to make it this global effort. And one of the things that, that is such a, common, factor that everybody shares that we find with all the moms is that there's the universal craving of moms for education and knowledge, particularly on a nutrition front. Whether it's their first child, their second, third, fourth, however many it's like, what can I be doing that's best for my child? What can I do that's gonna be better for this one than I may have missed, before? And it's this quest for knowledge of what are the best foods to eat? Where do those nutrients come from? And so that's why I wanted this global look. And so, yes, I knew going in, there'd be differences in all these places, obviously. But then these commonalities that came were so fundamental and this education, and so it was in all the settings, in India, maybe under the shade of a veranda clinic, Africa under great shade trees where a lot of schooling goes on gatherings of moms and communities. Or in Guatemala, in kind of little, community centers, and in Chicago, in centers or libraries, but also in homes. And so, the home visits, the lessons, the language was different, obviously in all the places, but the lessons. You know, it's whether it's a food bowl that they would use in Uganda or, in Guatemala, or a basket in India or our food pyramid or plate or, what we use here. And then the moms would say, okay, here's the foods that are in there. Here's the nutrients that are there. Here's how you find them. And then cooking and the cooking lessons. You see the reaction of the moms and it's like, oh, I never thought of cooking this way using potatoes in this manner of a cream of potato soup and you're adding the onions to that and other vegetables and milk and maybe some other protein, mixing that all together. It's like, well, how did you use your potatoes? I just boil them.

Brian Hanson: Mm-hmm.

Roger Thurow: And so it's like something that seems like almost no brainers in a sense, but it's revolutionary in practice, in education. But the inability then to put that knowledge into play, so that's where poverty then comes, is this big barrier. And that's everywhere again, we see with the moms in Chicago, then this knowledge becomes a burden. I know what I'm supposed to do. what I'm supposed to eat and where the food is coming from. But I can't afford it. I can't access it. Or it's not available in our communities. and so that aspect of it, so this communal teaching So Primeros Pasos is the clinic in, Guatemala, in the Western Highlands - the Meyer regions where they're growing so many of the fruits and vegetables that are so highly nutritious that we find in Whole Foods and in our stores in the United States, they're not in their diets. Moms are like in the fields, growing all these things and washing them and putting them into, crates, and putting them on trucks. And I ask one of the moms, so. Like, uh, do you eat any of this? no, we can't afford it. it's not really in our taste or our diets, but other people eat it. And I say, well, how do you know that? It's because we pack 'em and we put 'em on trucks and the trucks go away, and we're assuming that it's going someplace, in the stores in Guatemala City, or then it's being shipped up to other countries and in particularly to the United States. So when your grocery store and you see something that's come from Guatemala be like, oh yeah, these, it's grown by moms in the thousand days, and they're not, able to afford this themselves, or it's not in their diets or they're growing it, but the people that are owning the farms are saying, nope, uh, that's not for you. That's for export.

Brian Hanson: That's a big problem, right? I mean, 

Roger Thurow: mm-hmm.

Brian Hanson: people, and you talked about it a moment ago as kind of the burden of the knowledge. And you followed these families who dealt with this and found a way to, provide that nutrition for moms and children. What are some of the ways that we can overcome that part of the problem?

Roger Thurow: Well, like someone in the United States, there's the WIC program, Women Infant and Children's Supplemental Nutrition Program. That is vital because you see how important that is for families, that are struggling, how to provide money, to be able to afford these things. Our SNAP program, commonly known as food stamps. that program's so, critical. When you see the importance of that for these families, and there are similar programs perhaps in some of the countries like India with their great, food distribution. program, and you see how that doesn't get into the hands of everybody. There's holes in that, there's difficulties with the distribution, of that. The availability, the affordability of these foods, particularly the most nutritious foods, a lot of them is just also then breaking down barriers or cultural, barriers to this. And so in India, for instance, in Uttar Pradesh, so in the rural areas there, outside the town of Laal, for anybody who knows, it is common practice that the first breast milk, after birth is discarded as part of the kind of the purification process or of warding off evil spirits to cleansing that will then go on after birth. And it's like, no, that's the breast milk that then has the cosine that is so important for strengthening the immune system, for that to be the first substance that a baby is then taking and drinking. And so, then it's a matter of, okay, so how do we get past that barrier? And what kind of language needs to be used. And so even Indian doctors, and Bis Kumar then who, features, in the book and is the head of the community empowerment lab that's working with, the moms and the children and the families. He's from India, educated in India, then he was studying at, Johns Hopkins, and working at Johns Hopkins. And it was like, well, I just can't be like a doctor who then has studied in America with my white robot and say, this is what we must do. Because they'll all look at me and they'll say, what? and particularly mothers in-law, they'll say, that's not the way we did things. What? Why are you telling my, daughter-in-law or my daughter to do that? This is my grandchild we're talking about. He says, no, you're gonna see that these are really important things that will save their lives. So, breastfeeding, making that more widely, known and available again, the mom's choice. and in some instances, you know, it's not possible. So that's one of the things that then has talked about a lot, overseas and in this education.

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Brian Hanson: Nine years later, you've recently gone back to visit some of these families. And, by the way, for listeners who want to see more, in our show notes will post links to videos where you can actually spend time with these people and have Roger's narration of their experience. But for now, can you just tell a couple of stories of what the pathway for some of these children have been and how different is that than what the typical experience is in the communities in which they were raised?

Roger Thurow: We kept wondering, my wife and I, cuz she was with taking the photos and the videos, which people will see if they watch those, videos you just mentioned. You see the news of, wow, all this is going on in India and, in Africa… how is everybody doing? We get there and in all the places, everybody survived. The children all survived and are doing reasonably well. The parents, the grandparents, uh, even in most cases, nobody had even like suffered from covid, or died in their communities. And so it was like, well, this is extraordinary. So maybe the good nutrition in that period was a fortification for them, and strengthen them to overcome that, as well as other factors you know, particularly some that, you know…

There's Keytlin in Guatemala. So at two years old when the narrative begins, she's short, she's, frail thin, concerned that, yeah. Is she stunted? her mom. Dianet, she was very good student. She was taking notes. She would go home and then try all the recipes, the cream of potato soup and everything that they're learning, and then she'd report back, oh yeah, that was really good. And I've tried that and we've added all these things to it. And so she was getting creative with that. It was just the access to food and things that were going on in the family. So now we see Keytlin she is a wiz in school. She's top of her class she starts performing a play that she wrote, about a frog and you can't judge people by their appearances or a book by their cover.

(SOUNDBITE OF KEYTLIN PERFORMING PLAY)

Her mom spent whatever money she had, on books and so they were reading. So there's Keytlin, she's reading, uh, gave her again, a copy of the first thousand days in Spanish that we had, and she sat down and was going through that. We said, is she actually reading that since she's nine? And then she asked, well, what is this word? So it was like, okay, she was sitting there reading it. So I kind of wrote a little a note to her and said, the next time I come, I'll expect a book report. Uh, so she is very, sharp and overcame this from the mother's care and concern. And, you know, it's also the interaction with the caregivers to the child, the speaking to them, the notion that words are also nutrients for the brains. And so that's also important.

We visited in Uganda, the day we showed up in one of the villages, one of the boys, Rodgers, the name is not you know, coincidental. They figured well Roger is here during this time, so well, we'll name our son Rodgers. And he put a D in there and an S on the end, as is their way or the British heritage. It was his ninth birthday. And so his mom, Esther, she was also a great student and she had remembered that the midwife in talking about the good nutrients and where they come from and the vitamins and things on those posters, it's like a flip chart. And on the posters, one of 'em then had a child who was like playing soccer and running. It was like, okay, so with the vitamin A, this child will then be very active and will grow up like this. Another one had a child that was in school and kind of had a mortar board on it, It was like, uh, yes, iron and all these vitamins, it's important for this. So there she is, she's now working in the clinic herself, talking about these things now to other mom's and parents. She has these posters on the wall of her living room, and she's going through that and she comes to the picture of the boy playing soccer. And she says, that's Rodgers now at nine. He loves soccer. This is him. And then she flips over and there's the page of the child in class and learning. And she said, and this is Rodgers in his classroom today. He loves math. He loves going to school. And so these lessons that they had, that come to life as this child is there. So we celebrated his, ninth birthday, and they said, can you bring a cake up from, Kampala? The capital city. We said yeah we can have that, any flavor? And they said, ah, what's ever available? So bought a cake, kind of six hour drive up there, uh, hopefully it's not gonna melt or anything. And so there were four generations of the family there. So even the grandparents and the great grandparents, they were all there.

(SOUNDBITE FROM RODGERS BIRTHDAY PARTY)

Shyamkali, one of the moms in, India, uh, it's kind of through the course of the book. I don't wanna give away any kind of a dramatic moments, but she's so when we're following her and starting to follow, she's pregnant. She already has four children and they're all girls. And the big desire in Indian families, particularly in the rural years, is to have boys. And because girls, you got to educate them and feed them and take care of them, then they're gonna get married. And in India, you pay, it's the women's family that pays the dowry to the man's family. So it's like, oh, that's an economic cost. And then, our daughter, she's to go live with the husband's family. So it's the desire for boys. So she has four girls and then she's pregnant with a fifth child. And it turns out that is also a girl. So, when she gives birth to that fifth child, the first word she hears from the midwife that is delivering the child in this very kind of impoverished, wretched clinic. She gives birth on the floor. And the first word she hears is, I'm sorry.

Brian Hanson: Wow.

Roger Thurow: And just the reaction of her husband that we see in the society around her to keep trying then to have a boy. It deepens their poverty, the more children they have. She's very frail herself, she says, I shouldn't be having any more children, but you see that societal pressure and those cultural norms then of breaking them.

And Shyamkali had another child, her six daughter. But she's a fierce defender of her daughters and loves them all. And is committed to giving them as good as education as she can afford for them that they become independent and hopefully that they then are able to break this cycle of this kind of prejudice and discrimination of girls and women in India and to succeed despite all of that.

(SOUNDBITE OF SHYAMAKALI TALKING IN HINDI)

So, some tremendous stories.

Brian Hanson: So doggone, inspiring, especially where we started this conversation. If you think about one out of children in the world is stunted versus these kinds of outcomes. I wanna kind of shift our conversation a little bit to talk about the thing that you do, which is storytelling in order to bring about change in the world. And as listeners have had a chance to hear, these are very, very powerful stories about what is possible and as opposed to kind of dry abstract statistics which have their purpose. These stories are compelling because we can all relate to them, right? We have an emotional connection to the stories that you just told. And I wanna just ask about how you think about this work in terms of changing policy, cuz we've also heard you say in our discussion here, you know, this is about ending childhood hunger and that's what I'm about and why. Could you talk a little bit about storytelling as a tool for driving policy change and how you think about that and how you go about doing it?

Roger Thurow: It's become kind of the motivating passion of the driving force of my journalism to do this long, long form, narrative journalism and the great opportunity and privilege to be able to write a book, or a number of books and explore these things over time. I think as journalists, one thing we don't do very well is we don't go back to stories. You know, we would do a story, talk to people and there was a purpose for that. So why were we in that place? Why were we talking to those people? If we have the chance to kind of go back, and then use those stories kind of as a measuring stick. So what's happened over time? So to be able to go back to follow these families then through the thousand days, what has that intervention mattered? Right? And so to see this new emergence of this thousand days movement as being so critical for all of us. So what, did that matter? And so then I kind of wrote a new epilogue. digital epilogue, so it's on our site. And kind of called it beating the odds. And so that's, precisely what happened to, most of these children. There's some that, are still, struggling some, but they're all like reasonably thriving, they beat the odds of the one in four, in some of these countries, one in three in the western highlands of Guatemala, where Keytlin is and at the top of her class, is 70% childhood malnutrition and stunting and Guatemala as a whole, when I was doing the book, it was like 50% nationwide. So Guatemala has like the worst, malnutrition and childhood malnutrition rates basically in the Western hemisphere. And so that ability that I think to follow the people that we wrote about over time isa great privilege. And in terms of policy, I think that's what really helps policy makers to understand this ending hunger and malnutrition, wherever it may be, in whatever form it is, should be a top priority and you should understand that certainly on a moral basis, right? This is it, right? This shouldn't happen. We shouldn't have hundred people in our world today. But if the moral argument doesn't move you, one God help you. But two, here's the economic aspect of it. Three and a half trillion dollars, wow. Every year. Or maybe a security aspect, how secure and stable is our world? And Lizzy writes about it, how secure is our world with the hunger, with the poverty, with the, wealth gaps, with the racial discrimination and the social aspects in this world. How secure are we, as a society, as a people, as our world? We see all the manifestations of that, that flares up in, in all these conflicts, and if that still doesn't move you, this issue of the opportunity cost. We think about what might all these children, these one in four, what might they have accomplished for all of us? I think for decision makers, that profound notion of all these reasons why this should move you, this loss of potential, should make us all really think about and in this, storytelling, this longer form, storytelling over time, I think should be able to deliver this impact of this is kind of what the true cost or the true benefits are, as you say. I mean, kind of the good news of the delightful stories, right? Keytlin and Rodgers and kind of a number of the other children. So when you see that, then as a policy maker and these stories that how progress is made, how important these programs are, then okay, yeah, this works.

Brian Hanson: So Roger, as we bring the conversation to a close, I think there are a lot of listeners who are probably very moved by the stories that you told and how you brought this to life. And what would you encourage individuals to do? How can they make a difference and contribute to forward progress on these issues?

Roger Thurow: All of us should be asking what can I do? First of all it's just making yourself aware of these issues, and then, to become active, use that awareness when the next election comes long, whether they're, you know, local candidates national candidates, what are we doing about this? What was your position on these issues in the Farm Bill, on SNAP? On the kind of the school feeding programs, the lunch and breakfast programs that we have in the United States that are so important, that we have here. Right? If they're building schools or they're training teachers, or they're providing desks to schools or books, yay. That's all important, but what work is being done on a nutritional front? So when those children come to those nicer schools and sit in those newer desks, are they ready to learn or is their head basically on a desk because they're too tired and too hungry in the morning? And so organizations that are looking at that and kind of saying that development is this more, holistic effort that needs to be supported.

And if it really moves you, travel. Go see these things for yourselves. There are things that you see, that you can't unsee. And for me, it was in the famine of Ethiopian 2003. I was based in Switzerland for the Wall Street Journal, not writing about bike banks. Fortunately, we had other colleagues to do that. But writing about development and humanitarian issues, and the first hunger crisis of the 21st century, of this grand new millennium comes in Ethiopia. 14 million people on the dire verge of starvation being kept alive, if they're gonna survive at all by the international food aid that was coming into the country, led by the United States, you know, distributed by the World Food Program and so many other wonderful organizations on the ground. And my first day in Addis Ababa, I'm speaking with people from the World Food Program and one of them says to me, you know, Roger, looking into the eyes of the hungry becomes a disease of the soul. Because what you see is that nobody should have to die of hunger, particularly not now in 2003. In the subsequent days that I was traveling, we went to some of the hunger zones. We went into one of the hunger defeat tents, and there, for the first time, I really looked into the eyes of the hungry. There were like a number of tents that were set up maybe 60 or so children in, each tent with their parents, all in various stages of malnutrition, starving to death in their parents' arms. And there, saw and talked to one father, Tesfaye, his son hard. So, he was five years old and weighs just 27 pounds at the time. Doctors and nurses didn't know if he was gonna survive. And I left the tent that day, and normally as a foreign correspondent would've written my story and moved down to the next door -- that I talked about what's next, and then figured, this is the story that stops me cold, is the one that I have to keep coming back to, and back to, and back to Hunger in the 21st century. I've had the extraordinary privilege of then being able to follow my disease soul, where it would take me and to keep following Hagirso and his dad Tesfaye over time. And so, Hagirso is now in his, he's a young man, he's in his twenties. The last time I saw him, he was in the fourth grade. At 21 years old. That's the cognitive development, that's the long term impact. Of his classroom of about 60 children so, more than half of them were 18 years old and above, so they were older teenagers. They were young adults already. They had been so severely impacted by that hunger crisis when they were in that first thousand days, Hagirso was outta the first thousand days. But then his mom, she was malnourished the whole time during her pregnancy. He was low birth weight when he was born, always struggled during his early years, and so he was the most vulnerable when the famine happened. So, to be able to follow him and that then becomes, to me, this example of, this is the true cost of childhood malnutrition and stunting and it's stories like that. So again, as I say, travel, see these things make yourself open to this and that's kind of the power that it can have. So that's my testimonial on that front, that it changed my perspective, my life as a human being, but then also as a journalist and so what can I do? I'm not a farmer, I'm not an ag-scientist or an ag-economist or a development expert working for these great humanitarian organizations. I'm just a journalist. I mean, what can I do? We can raise the clamor. And by raising the clamor, they pay attention to these issues. These are our imperatives. And keep asking that question, what can we do? What can you do? And basically, what's wrong with us? That we continue to tolerate childhood malnutrition in 2023.

 Brian Hanson: Roger Thurow of the Chicago Council and Global Affairs --Thanks for sharing your experience and helping us understand this issue, that there are things that actually can be done and hopeful stories of what the world can look like if we continue to work on proper nutrition.

And listeners, I encourage you to check out his book “The First Thousand Days” and also look at the videos, because the boy he just mentioned meeting in Ethiopia, there's an extended presentation of his story that is fascinating and you can find that there as well. Links to all of these can be found in our show notes.

Thanks so much for being here, Roger.

Roger Thurow: Thank you, Brian.

[Brian Hanson: OUTRO: And thank you for tuning into this episode of Deep Dish.

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