Feeding the Future
SANMATENGA PROVINCE, Burkina Faso — In this tiny and impoverished West African nation, a visitor notices certain things.
In the rural north, it is the rugged beauty of the rocky outcrops that punctuate the barren landscape. In the capital city of Ouagadougou, it’s the mountains of smoldering trash piled on street corners. But nearly everywhere, it’s the children – dodging mopeds on chaotic streets, tending herds of cattle, or cradled in their mother’s arms.
Children make up an outsized proportion of Burkina Faso’s population. According to 2012 United Nations estimates, 45.2 percent of the country is under the age of 14. The same is true throughout the world’s least developed countries, where an estimated 40 percent are under the age of 15. And nearly all population growth models project the ranks of the world’s poorest youth will continue to multiply.
Dependent on scant and unreliable food sources, hunger is already a harsh reality for many children. And what little food they do have does not supply the nutrition they need to grow and develop normally.
Malnutrition is a major issue in places like Burkina Faso. But despite its global magnitude, the problem has been largely kept quiet. Lacking the resources to respond, countries with the greatest nutrition deficits have kept the problem shielded from the public eye.
In 2011 alone, malnutrition was complicit in the deaths of 3.1 million children worldwide. It impedes cognitive and motor development and as a result, malnourished children are often significantly less productive than their peers as adults. Many nations are paying a steep price: estimates show that malnutrition decreases a country’s economic growth by at least 8 percent.
But now there is hope, here in Sanmatenga Province and elsewhere. A new global nutrition movement is underway, involving – perhaps most critically – the United States Agency for International Development (USAID), the world’s largest food aid donor. After 60 years of supplying lifesaving food aid to more than 1 billion people in 150 countries, USAID is undertaking an unprecedented reappraisal of its food aid program to see how it can improve the nutritional quality of the products it provides, especially for malnourished children.
Recognizing the moral, economic, and developmental interests at stake, USAID released an agency-wide nutrition strategy in May – the first in over 20 years.
“Since our food aid program started in 1954, the intensity and complexity of hunger—and our understanding of it—has changed,’’ USAID Administrator Rajiv Shah said in a 2013 speech. “Applying the latest in nutrition science, our food aid basket is undergoing the largest transformation since the program began in 1954.”
Faced with a tightening food aid budget, USAID is testing new food products in Burkina Faso, to figure out the most cost-effective way to prevent malnutrition. The results will help determine how USAID feeds millions worldwide. But obstacles remain on the ground, ones that cannot be overcome through food products alone.
On the front line
It’s 8 a.m. and already, a crowd has formed. Draped in traditional garb – dizzying patterns of fluorescent green, yellow and red – hundreds of women and their children wait outside a small warehouse in a dry northeastern corridor of Burkina Faso called Sanmatenga province.
A large tree hangs nearby, one of few in this desolate landscape. It is a popular gathering spot for mothers and their children seeking respite from the searing heat. Their bikes are parked in a growing jumble nearby.
Some have walked or pedaled as far as 10 miles today, as they do every month, to receive supplementary food rations supplied by Victory Against Malnutrition, a five-year development project funded by USAID.
Amidou Kabore – Victory Against Malnutrition’s field director – observes the scene outside the warehouse. As a native Burkinabe who has spent 25 years with the government and private volunteer organizations working on projects like this one, he has seen the effects of malnutrition. So the program’s objectives are deeply personal.
“For the government and for everyone, the first problem in Burkina is food security,” he says. “You can’t develop a country when people do not have enough to eat.”
This dusty region of Burkina Faso – Sanmatenga province – means “country of gold” in the local tongue. The precious element is found in abundance beneath the fine red soil. But here, nutritious foods are scarce.
Nearby, the remains of last month’s harvest, broken stalks of sorghum and millet, lie shriveled in the mid-day sun. On average, this area receives 23 inches of rain annually, a four-month deluge dumped from the sky between June and September. But once the rains stop, these lands will not see another drop for nearly eight months. The harvest must sustain these people for the next year.
According to Kabore, year after year, supplies dwindle at the start of the rainy season, just when they’re needed most. In fact, locals have a word for it – “ware” – their name for the four-month spell of food scarcity, which coincides with a period of intense farm work necessary to ensure a good harvest. It’s a cruel cycle, but a reality of life for many in the Sahel region.
Seasonal food shortages are not the only obstacle facing the people of Sanmatenga. The absence of certain food groups from their diets impacts those most vulnerable here – young children and pregnant women. The hot, dry climate means fruits and vegetables are especially hard to come by.
In the few areas with enough water, villagers grow tomatoes, onions and some cabbages, but typically sell what they harvest. Vegetables command high prices at markets, and are a luxury few here can afford. But the most significant absence is a source of animal protein. Some Burkinabe raise animals – small herds of goats, cattle and chicken – but very few eat them, preferring instead to sell their meat and milk to meet the family’s financial needs, Kabore says.
For these reasons, moderate acute malnutrition (MAM) is a serious issue among the children of Burkina Faso and particularly, Sanmatenga province. Commonly referred to as “wasting,” MAM is defined as a weight-for-height ratio significantly below the established World Health Organization averages. A 2010 health survey conducted by the Burkinabe government found nearly one in seven children in the country showed signs of the debilitating disorder.
For Victory Against Malnutrition, food products provided by USAID are the spearhead in the fight against malnutrition. All of these women waiting for food are pregnant or have children under the age of two, which qualifies them to receive supplementary rations of corn soy blend, yellow split peas and vegetable oil fortified with vitamins A and D. Any child between six and 23 months of age is also eligible, but there are a few stipulations. In order to receive their monthly rations, the women must attend regular nutrition education seminars in their villages. Once a month, they must also bring their children to the health centers interspersed throughout the area to be screened for signs of malnutrition.
Few images are more visceral than the sight of a starving child, so local health workers are able to spot and treat cases with relative ease.
But there is another problem that exists among these children – chronic malnutrition. It’s equally insidious, but less obvious to the naked eye.
An invisible problem
A result of prolonged and persistent nutritional deficits, chronic malnutrition is best measured as below average height for age and manifests itself in the disorder known as stunting, according to UNICEF.
It’s a major problem here and throughout the developing world: a 2010 government study found that 34 percent of Burkinabe children are stunted.
Actual rates are likely higher, because chronic malnutrition is difficult for parents to spot in the first place, no less local health officials. In Burkina Faso – where families struggle daily to fulfill their most basic needs – it’s not hard to see how a child, who is shorter than normal for their age, could be overlooked.
“With chronic malnutrition, people don’t feel it,” says Gerald Zafimanjaka, health and nutrition director for ViM. “It’s not obvious, but we know that it will affect the future of this country in terms of education and poverty.”
Other factors play a role in chronic malnutrition, including poverty, and diseases like malaria, tuberculosis and HIV. But in Africa, the lack of a diversified diet is often to blame. The result is a crippling downward spiral that is difficult to escape.
For many children who suffer from it, the disorder begins before they start eating solid food and often before they’re even born.
Dr. Kerstin Hanson, a pediatric nutrition advisor for Doctors Without Borders, says many children in Africa are born underweight – and at risk of becoming sick and malnourished – because their mothers are undernourished during pregnancy. “From the time of conception, the fetus needs to be getting the proper nutrition, so mothers need to have access to prenatal care, prenatal vitamins and nutrition so that it can develop normally.”
After birth, exclusive breastfeeding during the first six months of life is the best way to ensure a child is receiving the fat and protein it needs. But according to Hanson, it’s when children are weaned that problems often arise, especially if the mother doesn’t get them on a proper diet.
It is not uncommon for adults in developing countries to go extended periods of time without enough to eat, subsisting on grains and other carbohydrates that provide energy but little else. During the “lean season,” waists shrink and energy levels drop but for most, life goes on. But the nutritional needs of young children are far more complex.
The first two years of a child’s life are a period unlike any other, and not simply in terms of physical growth. Here, the foundations are laid for many of the body’s major systems, including the brain.
During this time, children have very specific dietary needs – macronutrients like carbohydrates, proteins and animal lipids, which promote physical growth and contain the fatty acids that neurons in the developing brain so desperately crave. Micronutrients like Vitamins A, K and D, zinc, folic acid and iron are also critical for the development of the immune system, brain and blood, according to Hanson.
In the United States, most children have access to these nutrients. Milk and orange juice are fortified with Vitamin D, salt with iodine, cereals and baby food with iron and other essentials. The sheer variety of food available on shelves in America functions as a kind of safety net against chronic malnutrition.
In places like Burkina Faso, this is not the case.
In the short term, a nutritionally insufficient diet can cause delays in walking or speech. But as malnutrition becomes chronic, speed bumps can turn into permanent roadblocks.
“A diet based on a grain-based porridge often lacks the essential fatty acids, lipids and vitamins needed for brain development,” says Hanson, the Doctors Without Borders advisor. “Brain development will be slowed and at a certain point, a child won’t be able to catch up later.”
The consequences of chronic malnutrition for both individuals and societies are difficult to quantify, but the growing body of evidence is clear: proper nutrition in the first few years of life is critical to intellectual development and long-term productivity. But for cash-strapped, resource-poor governments, ensuring that children have access to a stable, diverse supply of food is too big a burden to handle alone.
Instead, the responsibility falls to others to close the nutrition gap. In Burkina Faso, private volunteer organization workers funded by the U.S. government – distributing U.S. food aid products – are often the first responders to the problem.
USAID has been active in Burkina Faso for many years. Since 2010, it has provided $74.8 million in emergency and development food aid to the country. But the agency is about to play a bigger role, as part of a new movement to address malnutrition.
The nutrition revolution
In releasing its new, comprehensive nutrition strategy in May, USAID acknowledged the scale of the global nutrition problem by proposing changes that will enlist the participation of all its bureaus worldwide. Among its lofty goals: reducing stunting in children under five by 20 percent, and to reduce the number of stunted children by a minimum of 2 million by 2025.
Its push to address chronic malnutrition accelerated six years ago with the publication of two separate reports. The first was a January 2008 series published in the influential medical journal The Lancet, which sharply criticized the way government food aid programs deal with maternal and child malnutrition.
The report’s authors cited international aid donors – including USAID – for what they called “grossly insufficient and poorly targeted” funding for nutrition initiatives. The findings shook the nutrition and food aid community. And while not short on strictures, the reports also offered solutions, which have shaped USAID policy in the years since.
Up to this point, most government-funded nutrition programs targeted children up to 5-years-old with supplementary feeding, but only after signs of malnutrition appeared. In a study examining a Food for Peace-funded program in Haiti, researchers found strong support for a proactive approach to malnutrition prevention, and corroborated existing evidence identifying the first two years of life as the most critical period for a child to have proper nutrition.
“That was sort of a landmark study that said, ‘OK, we provided this amount of nutrition during this period and we saw relatively enormous gains in prevention of stunting,’” says Melanie Thurber, a nutrition advisor for Food for Peace, the central office for U.S. food aid programs.
Today, nearly all USAID development projects focused on nutrition emphasize the importance of the first 1,000 days –from the start of a woman’s pregnancy until her child’s second birthday – as the key timeframe for preventing the long-term impacts of malnutrition.
On the heels of the Lancet reports, USAID commissioned a thorough review of its food aid products with the 2011 Food Aid Quality Review (FAQR), conducted by researchers from USAID and Tufts University’s Friedman School of Nutrition Science and Policy.
One primary focus: Corn soy blend (CSB), which has long been the workhorse of the U.S. food aid basket. A blended flour made of corn meal, soy and fortified with vitamins and nutrients, CSB can be boiled in water to make a simple porridge for children. The product has been distributed in emergency and non-emergency situations for over five decades, and had drawn some complaints from aid groups like Doctors Without Borders, who claimed the product was substandard.
Dr. Beatrice Rogers, co-lead researcher for the FAQR and director of Tufts’ Food Policy and Applied Nutrition program, said her team was initially approached by Food for Peace to review the composition of corn soy blend. “There had been periodic updates [of CSB] but they were saying there hasn’t been a really good, scientifically-based review,” she said.
The report advised that USAID update the vitamin and nutrient profile of the product. But perhaps the most significant recommendation was to reformulate the current generation of CSB to add a dairy protein component, in the form of whey.
For many years, CSB did contain milk powder, a valuable source of animal protein. But in the mid-1980s, due to rising costs and decreasing availability, the milk powder was removed. Today, there is mounting evidence that animal protein is vital to normal development. Exactly why remains a mystery.
“The flippant answer is that we don’t know, but that is actually the real answer,” said Dr. Patrick Webb, co-lead researcher for the FAQR and Dean of Academic Affairs for Tufts University’s Friedman School of Nutrition Science and Policy. “The evidence we have suggests that animal-sourced protein carries something with it, that we have yet to identify, that is an important promoter of both cognitive and physical growth.”
Per FAQR recommendations, USAID has taken steps to modernize and diversify the types of products it provides. USAID is now distributing ultra fat- and energy-dense pastes called ready-to-use therapeutic foods (RUTFs) to bring starving children back from the brink. The food can be squeezed directly from 100-gram sachets and eaten with no preparation, and kids love the taste – peanut butter cookie dough, with a slight metallic tinge.
“Until recently, a starving child had to make it to a medical facility if she had any hope of survival,” said USAID administrator Shah said in a speech last year. “Today, she can be treated at home with products that don’t require refrigeration and don’t need to be mixed with water — a serious limitation where clean water is scarce.”
Several other next-generation products are in use or scheduled to come out soon – from non-perishable meal bars that fed survivors in the aftermath of Typhoon Haiyan, to new fortified foods like ready-to-use supplementary food (RUSF), formulated to prevent child malnutrition.
But these advances and the agency-wide move to address nutrition come at a trying time for U.S. food aid.
The Lancet estimates that just $3 to $4 billion from donors could make a “significant difference to childhood nutrition,” but the office of Food for Peace – which funds the bulk of U.S. food aid efforts – continues to see its resources diminish, another casualty of ever-tightening federal budgets. And even with modest budget cuts, the amount of food the U.S. ships overseas with the funds available has plummeted, in part due to rising transportation costs. In 2012, the U.S. shipped less than half the food aid in tons that it sent abroad just nine years earlier.
As its costs soar, and the ranks of malnourished children remain high, USAID has embraced the role of bargain shopper. Forced to do more with less, Food for Peace is field-testing some of these new foods in Burkina Faso this year, with the goal of finding the most cost-effective products to prevent malnutrition.
Testing foods of the future
Two wheels are the preferred mode of transportation here – with or without a motor – and at the end of a winding, tree-lined dirt road in the capital of Ouagadougou, Nadira Saleh parks her bike outside a shabby concrete building. Its walls, likely white long ago, are now a pale orange hue, stained by the fine red sediment invariably suspended in the air.
Above the entrance, a creaky metal double-door, hangs a faded sign: “Institute de Recherche en Sciences de la Sante.” Saleh’s office, which she shared with another researcher, sits at the end of a dim hallway in this branch of Burkina Faso’s Research Institute of Health Sciences. There is not much in here: the walls are bare and the shelves empty, save for some old office equipment. When she is thirsty, which is often in this heat, Saleh goes down the hall to fetch a plastic pouch of water from a refrigerator in the building manager’s office. But on nights when she is stuck working late and the office manager has locked her door, she is out of luck. It’s not glamorous by any stretch, but the work she is doing here is vitally important to the future of U.S. food aid.
Saleh is a field research coordinator contracted by Tufts University and USAID, tasked with laying the foundation for a 3 ½ year study, which began distributing four different supplementary nutritional products to the children of Sanmatenga province in spring 2014.
On her wooden desk sit several small packets of USAID’s new formulation of RUSF and a larger metallic packet labeled “Super Cereal Plus.” Saleh tried to bring these packages over from the States in her suitcase, but drew the attention of Burkinabe Customs officers at the airport. Luckily, she was able to flash the right documents to keep them. In the coming months, much more food will be on the way.
“This research has the potential to change policy and products that people are receiving as part of a greater campaign to reduce malnutrition,” said Saleh, who recently left Burkina Faso. “This deals with the immediate needs that families may face, so if we can fortify those or make them stronger, that’s definitely a wonderful thing for us to be involved with.”
The study has partnered with Victory Against Malnutrition to enroll children as soon as they turn 6 months old, and provide them with supplementary rations until they are 2 years old. But these children, who would have previously received CSB and fortified vegetable oil, will receive different foods, better formulated to provide them with the macro and micronutrients missing from their diets.
The foods being distributed in Burkina Faso are CSB14 – a new corn soy blend formulation containing additional micronutrients and whey protein, per Food Aid Quality Review recommendations – and two other similar corn and soy based blends, Super Cereal Plus and Corn Soy Blend Plus (CSB Plus). The fourth is USAID’s version of the fortified peanut paste known as RUSF. Each product is different: some, like CSB14 and CSB Plus, require preparation with added oil. Others, like Super Cereal Plus, do not. Then there’s RUSF, which children can eat directly from the packet.
“What we’re asking has to do a lot with the process. We’re saying, ‘These people get the food, but what could make it more or less effective?’ ” said Tufts’ Rogers, who is the principal investigator for the study. “It could be the food itself; it could be the ability to prepare it properly; it could be that one food is more likely to get shared [within the family] or diverted to other uses. The costs per kilo are very different for these foods; even the costs per dose. But what we don’t know is the cost per case of malnutrition effectively prevented.”
Although important, the study in Burkina Faso is just one of several unfolding around the globe.
But as USAID works to develop the evidence base that will guide its nutrition policy, the entire U.S. food aid program remains on unstable ground. On Capitol Hill, pork-barrel politics means that food aid is closely tied to aid programs that benefit farmers and other special interest groups. There have been proposed reforms, measures that would give Food for Peace the flexibility it needs to respond to hunger and malnutrition around the world. But in the current economic and political climate, the possibility of further cuts still looms.
“My concern is that if government cuts continue the way they have, food aid will certainly not be immune to those,” says Webb. “We may end up with very strong recommendations about how to improve the quality of products and programming, at a time when food aid continues to decline as a global resource.”
Progress, but problems remain
In the meantime, life goes on for the people of Sanmatenga province. Not far from the food distribution site near Delga, where the next generation in food aid products are being distributed through the Tufts study, a few women and their children sit on a concrete bench in the covered courtyard of a small, open-air health center. In a windowsill, a filthy green tray sits overflowing with empty vaccine bottles.
This is a government-funded health facility that serves Delga and 10 other surrounding villages, where women and their babies wait patiently to see a government health worker named Pascaline Ouedraogo. She has been here just three months, but already carries tremendous responsibility. There are several examination rooms in the health center, but Ouedraogo is the only maternal and child specialist here, tasked with handling the myriad health concerns of hundreds of women and their children. Perhaps most importantly, she is the sole person in charge of screening children for malnutrition. To receive the food sent from the U.S. and distributed by Victory Against Malnutrition, mothers must have their children screened here once a month.
One by one, Ouedraogo places each child into a blue cloth harness, like the baby seat on a playground swing set. While their legs dangle feet above the ground, tears begin to run. Many cry and reach longingly towards their mothers. A UNICEF scale hung from a crossbeam weighs each child, which Ouedraogo records on a nearby growth chart.
Next, she wraps a measuring tape around each child’s upper arm, between the elbow and shoulder, to measure its girth. The band is color-coded: green is a sign of good health, but yellow means the child may be malnourished. If the child is in the red, there is a very real risk of death. On average, Ouedraogo says she receives around 40 children each month in the yellow with signs of moderate malnutrition as part of testing she does for acute malnutrition.
The last part of the screening, used to detect chronic malnutrition, is the most time-consuming and labor-intensive. She does her best to lay the children flat on their backs on a notched piece of wood, but often enlists the mothers to help control the kicking and squirming. Their heights are recorded on growth charts.
For Ouedraogo, the workload is overwhelming. Each Friday, around 100 children arrive needing screenings. But there is only so much time and often, she must turn some away.
“It is very difficult,” she says. “If a lady is in labor and comes to give birth, I have to stop the regular clinic visits, attend to the lady, and come back. So it’s not easy, and it’s very tiring.”
According to Kabore, Victory Against Malnutrition’s field director, this situation is common in many of the country’s health centers.
Ouedraogo also deals closely with the mothers, who are often part of the malnutrition problem here. Once their children are weaned, many mothers fail to introduce complementary feeding properly. Some will wait for their children to walk before feeding them porridge, fearful that with extra weight on their bones, this milestone will be delayed. In some villages, traditional beliefs forbid young girls from eating eggs, one of the few sources of animal protein available.
Victory Against Malnutrition has a staff of 25 health and nutrition promoters, who work with these health centers to educate the mothers about proper nutrition.
In Burkina Faso and other countries like it, the fight to end child malnutrition clearly will not be won with food products alone. USAID is aware of this fact and in its forthcoming nutrition strategy, acknowledges the integral roles that sanitation, education and family planning can also play.
But food aid remains a key part of the solution, and USAID officials and others in the nutrition community will be watching the results of the Burkina Faso study and others like it very closely.
“We’ve identified 68 ongoing and planned studies relating to food products of varying kinds around the world right now,” says Webb, whose Friedman School of Nutrition Science and Policy is involved in three of those studies. “It’s the collective science that will influence the future direction of USAID.”