“When you arrive in a village, everything may seem normal at first but then you start to notice things”, explains Kenyan Assumpta Ndumi. “It is lunchtime but there is no food on the fire. There are children in the village but no laughter or play. These are some signs of chronic malnutrition.” For Assumpta, Save the Children’s nutrition adviser for East Africa, chronic malnutrition is a problem every bit as serious as acute malnutrition, even if it seldom captures the headlines. “In Kenya last year, the acute malnutrition that followed the drought was widely reported but even before the rains failed there was a hidden hunger and children were dying because of it.”

Through her work, Assumpta has witnessed firsthand the situation faced by children in Ethiopia, South Sudan, Darfur, and Kenya. “Many families eat just one meal day, but it is often the quality rather than the quantity of the food that they eat that leaves them dangerously weak” she said, pointing to reliance on staples such as maize and cassava which have low nutritional value as well as the lack of fresh fruit and vegetables. 

But Assumpta has also seen how simple, low-cost interventions can have a significant positive impact, transforming lives and preventing unnecessary deaths. According to “A Life Free From Hunger,” a new report by Save the Children, nearly two in five children in Africa – 60 million in total – are chronically malnourished. The report argues that malnutrition is the underlying cause of one third of the children’s deaths worldwide although it may not appear on their death certificates. Secondary illnesses such as diarrhea, pneumonia and malaria rather than chronic hunger are usually put down as the cause of death.

In addition to causing fatalities, chronic malnutrition is having a devastating impact on children’s development. Without the necessary protein, vitamins and minerals, children’s bodies and brains do not develop properly. In Niger, for example, recent World Health Organization research shows the average two-and-a-half-year-old will be more than 8 centimeters shorter than a well-nourished child, and a 2011 UNICEF study found that one in three children in Zimbabwe suffers from chronic malnutrition.

Malnourished children often suffer from diminished IQs, and if they survive to adulthood are more likely to suffer from heart disease, diabetes and renal damage as well as being far less productive members of society.

Despite a significant global reduction in child deaths, progress on tackling chronic malnutrition has been painfully slow. While the past twenty years has seen the number of deaths from tuberculosis fall 40% globally and deaths from malaria fall by over 30% in Africa, levels of stunting across the continent have dropped by just 1% over the same period. There are now growing fears that a combination of trends including rising food prices, climate change, and demographic shifts could reverse even this modest gain. 

In a recent survey, also by Save the Children, half of families polled in Nigeria, Pakistan, Peru, India and Bangladesh said they were forced to cut back on food last year. The poll also found that one in six parents asked their children to skip school in order to work to help pay for the families´ food. In Nigeria, a quarter of all parents surveyed said their children sometimes or often go without food for an entire day, and 94% pointed to rising food prices as their most pressing concern. 

According to Assumpta, tackling chronic malnutrition is neither difficult nor expensive. “I have seen how encouraging breastfeeding and fortifying basic foods with essential minerals or vitamins can have an immediate and dramatic impact on children’s health,” she said. Back in 2008, the Lancet medical journal identified an affordable package of 13 direct interventions – including vitamin A and zinc supplements, iodized salt, and the promotion of healthy behavior such as breastfeeding – that were proven to have an impact on the nutrition and health of children and mothers. It is estimated that it would cost little more than $10 billion per year to implement this package and help protect 90% of the world’s most vulnerable children from hunger. 

According to a 2011 FAO report, three quarters of Africa’s malnourished children live on small farms and 43% of agricultural work is carried out by women. Key to improving nutrition is therefore improving agriculture among small holders, sharecroppers and agricultural laborers, particularly women, by ensuring increased access to vital inputs such as land, tools, fertilizers and seeds, credit, agricultural services, markets and water. Integrating strategies on health, nutrition and agriculture has been shown to produce positive effects. In Mozambique, for example, where the Food Security and Nutrition Strategy is overseen by the Ministry of Agriculture, a significant decline in malnutrition rates has been achieved. 

But despite some limited successes, nutrition-focused agricultural interventions are not able to address the underlying causes of malnutrition such as chronic poverty and maternal health. In Rwanda, despite efforts to promote balanced diets and the introduction of specific structural anti-poverty interventions including the provision of school milk and kitchen garden projects, rates of malnutrition remain stubbornly high. “The roots of malnutrition are anchored in poverty and behavior,” Rwandan health minister, Agnes Binawahlo, explained this week. “Only sustainable development based on education and economic growth can beat it.” 

For Assumpta, who has worked to tackle malnutrition for nearly two decades, the fact that chronic malnutrition can be alleviated with simple interventions gives her hope, but it also increases her frustration when she sees its devastating effects. “Last February, an old woman arrived at an outreach centre in Wajir, north eastern Kenya carrying a listless child,” Assumpta recalls. “I thought the girl was about two years old but the woman, her grandmother, told me she was five. The girl – who was very thin and had a cough and breathing-difficulties – did not survive the night. In the morning we drove them back to the village. The child’s mother and father came out to meet us. I watched from the car as the grandmother walked towards them carrying that small lifeless bundle wrapped in a blanket in her arms.” Stories like this are all too common and highlight the urgent need for a concerted global effort to tackle malnutrition.

“A life free from hunger: Tackling child malnutrition” available here

Stefan Simanowitz is a writer, journalist, photographer and broadcaster.  

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