The First 1,000 Days

Three mothers try to break the cycle in the first 1,000 days of life By Roger Thurow

On the front lines of childhood malnutrition

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The solution begins in the first 1,000 days of life—from the beginning of pregnancy to the second birthday of a child.

Importance of the first 1,000 days

What happens in those first 1,000 days determines to a large extent the course of a child’s life—his or her ability to grow, learn, work, succeed—and, by extension, the long-term health, stability, and prosperity of the society in which that child lives. Babies growing in the womb receive all nutrients from their mother. If she lacks key vitamins and minerals in her diet for her own health, so will her baby. For infants, breast milk provides an array of vital micronutrients and an early immunization against illness and disease that helps fortify the body. Once complementary feeding begins, usually around six months of age, healthy foods ensure continued growth and brain development. Foods introduced at this time also shape a child’s lifelong relationship to food and the body’s reaction to it. Any prolonged shortage of food or persistent lack of vital micronutrients such as iron, zinc, iodine, and vitamin A in the first 1,000 days can set back growth and development, sometimes irreversibly. A child with stunted cognitive development has difficulty learning in school and drops out early, which diminishes the child’s prospect for success in the labor force. The impact spreads to the family of the stunted child, who will likely earn less than a full wage and incur higher healthcare costs than would otherwise be necessary, making the family’s climb out of poverty that much more difficult. For many families, the impact of malnutrition and stunting steamrolls through the generations in an accumulation of historical insults: stunted girls grow up to be stunted women who give birth to underweight babies. The ripples from stunting then widen to engulf the community, for where there is one malnourished child, there are certainly more. Labor pools are depleted, productivity is sapped, economic growth lags. In the same way, entire countries and continents are crippled.

The losses are immeasurable:

What might a child have accomplished were he or she not stunted?

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These are stories from the first 1,000 days and beyond (as first featured in the book The First 1,000 Days)

Roger Thurow on Maria’s experience

Maria Estella Lopez works in the fields where farmers grow nutrient-rich vegetables that fill the shelves of American grocery stores.

Children in this region are…

Yet these communities are among the most malnourished in the world, the legacy of four decades of civil war and neglect that left the area ravaged.

The legacy of civil war and neglect

The decades-long civil war, which ended in the mid-1990s, was particularly brutal in the highlands, where the government fought rebel groups who had support among the indigenous communities. Infrastructure collapsed, health services vanished, and the agriculture-based economy was ravaged. Widespread atrocities and human rights violations by government forces triggered claims of genocide. It is estimated that up to 200,000 people were killed or “disappeared” during the war. More than two decades later, poverty and neglect still reign in the highlands.

TOO MUCH CORN Despite lush vegetable patches that dot the landscape, corn makes up three-fourths of the local diet. Farmers spend much of the money they earn from the export of other vegetables buying more corn. While the tortillas, tamales, and chips made from it are cheap and filling, they are thin on diverse nutrients.

Maria’s first child, daughter Yesica, was small at birth and slow to walk and talk. She feared it was due to malnutrition. Pregnant again two years later, Maria was desperate to avoid the same fate for her second child.

Public health services had been rare in the Palajunoj Valley until Primeros Pasos, or “First Steps,” arrived. It started as a research project by American Brent Savoie in an abandoned mission clinic to study the impact of parasites on child development. After the project ended, he kept the clinic running. He raised money and expanded its program to provide essential prenatal care, vaccinations, child health checks, medicines, and education. It is the only organization in the area that offers reliable healthcare and nutrition instruction for women and children.

“When you are pregnant, you must eat more than tortillas.”—Susy, a nutritionist for Primeros Pasos

Primeros Pasos fills the gap

This time, she was able to join a 1,000-day program run by the local clinic Primeros Pasos to learn how proper nutrition could give her child a better start.

Maria learned about the importance of vitamins and minerals throughout pregnancy and beyond. She learned how to cook and include the nutrient-rich vegetables she helped grow in her family’s diet.

A RECIPE FOR HEALTH A Primeros Pasos instructor demonstrates how to cook a nutritious meal: cream of potato soup with Protemás (soy protein).

Jorge at birth weighed more than eight pounds, far above average, beating the odds in Guatemala.

MARIA EXPANDS THE FAMILY’S DIET Maria proudly shows off her efforts to diversify the crops she grows in her garden, adding a greater variety of vegetables and fruits. She also expands her poultry farming, adding ducks and turkeys with her chickens—all to improve the nutrition in her family’s diet.

By age 2, Jorge was almost the same size as his sister, who is nearly twice his age, thanks to better nutrition.

HIGHER NUTRIENTS = HIGHER WAGES A study in eastern Guatemala that now spans five decades shows that children who are well nourished in the first 1,000 days stay in school longer, have higher test scores, and earn up to 40 percent more in wages as adults. They are also less likely to develop a chronic illness. Source: Institute of Nutrition of Central America and Panama Oriente Longitudinal Study

At age 5 he was active, robust, and excited to start school. Clearly he is not stunted.

Brenda Okullu and others like her work in the fields where two new nutritious crops—vitamin A-enriched orange sweet potatoes and beans high in iron—were introduced to farmers by the global HarvestPlus program and its partners.

The low-tech fields in which Brenda and thousands of other farmers in Uganda grow crops are on the cutting edge of cooperation between agriculture and nutrition known as biofortification. Through conventional breeding, staple crops—the food people eat every day—are fortified to raise their nutrient content as well as resist disease and pests and adapt to climate changes. These crops are the result of a decades-long quest by Howarth “Howdy” Bouis, founder of HarvestPlus, to improve nutrition through biofortification. He, along with Drs. Maria Andrade, Robert Mwanga, and Jan Low, received the 2016 World Food Prize for this breakthrough.

The life-changing sweet potatoes of HarvestPlus

Brenda, whose first child died two weeks after birth, was a model mother for her second child, Aron.

“THE BABY KICKS A LOT. MY LIFE IS GOOD.” Brenda felt much better with her second pregnancy. She suffered fewer headaches, had more energy, and expected to work in the fields until she had the baby. She thanked the new crops for her added pep. It must have been them, she said; nothing else had changed.

She used what she had learned through the 1,000-day programs of HarvestPlus and World Vision throughout her pregnancy, eating the sweet potatoes and high-iron beans that she grew herself.

ARON’S 1,000-DAY DIET Brenda also gave Aron the iron-fortified beans, corn, peanuts, and assorted greens that grew in her fields. He got milk and meat from their cows and eggs from the chickens.

Aron continued developing well, thriving on his mother’s nutrient-rich breast milk and eventually those same sweet potatoes.

Then at about six months came a scare. A local well became contaminated, and both Brenda and Aron came down with dysentery.

Bad water and poor sanitation undermine progress on nutrition

Although she had done all she could to give Aron a proper start in life, she almost lost her son to a few sips of bad water.

While there has been considerable progress in recent decades, access to clean water and improved sanitation varies widely in low- and middle-income countries. An estimated 660 million people worldwide still use unimproved drinking water sources, including unprotected wells and springs or surface water from rivers and lakes. And more than 2 billion people either still use unimproved poor sanitation facilities, such as uncovered latrines, or defecate in the open. Source: United Nations Children’s Fund and World Health Organization, Progress on Sanitation and Drinking Water, 2015

Luckily, Aron recovered and continued his strong development. At age 2 he was an active and curious child.

At age 3½, he was already in kindergarten, proudly wearing his school uniform.

Roger Thurow on Maria’s experience

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SHYAMKALI & ANSHIKAGIRLS EAT LAST AND LEAST

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Discrimination against girls runs deep

Shyamkali is the mother of six girls in a place that values boys.

India is one of the rare countries with far fewer girls and women than boys and men due to female infanticide and feticide and the neglect of the well-being of daughters. In Uttar Pradesh there were only 904 females to every 1,000 males according to the last census in 2011. The problem is so widespread that it is illegal for parents to even ask a doctor about the sex of a child after an ultrasound. And doctors who disclose the sex can be stripped of their medical license and thrown into prison.

In the little villages near the town of Shivgarh, boys carry on the family line, are valued for their earning potential, and bring honor to the house.

Girls are thought to bring certain economic loss, with the family’s money given away in dowries and their labor and children eventually lost to the husband’s family.

Had Shyamkali and her husband had a son, they would have stopped having children. Instead, they continued trying for a boy, stretching their limited means further.

When Shyamkali gave birth to Anshika, the midwife said: “We’re sorry. It’s a girl.”

Saksham, a community health program to empower women, has made progress on changing local customs to encourage giving birth at clinics, breastfeeding as soon as possible after birth, and giving girls and mothers healthy food.

Driven by a desire to tackle malnutrition, stunting, and infant and maternal mortality in his native India, global health doctor Vishwajeet Kumar began working in rural villages in Uttar Pradesh around the town of Shivgarh. Traditional practices here, deeply rooted in the region’s caste system, culture, and spirituality, were profoundly impacting the first 1,000 days. Bringing research and knowledge gained from his time studying with top child health experts at Johns Hopkins University, Kumar’s team and community leaders—including trusted young women from the villages—spread the word about how some simple behavior changes could save their lives and the lives of their children. His efforts worked, and the Community Empowerment Lab, or Saksham to the locals, was born. Today Saksham continues its community-based global health research, innovation, and programs to save and change lives in the first 1,000 days and beyond.

Saksham saves lives through cultural change

Food was scarce in the house. The family didn’t have a ration card, so it couldn’t participate in the government’s distribution of subsidized food. The regular distribution of the panjiri, fortified flour distributed to pregnant and breastfeeding mothers and to their infants, had also stopped throughout the Shivgarh area. Shyamkali’s husband, Rajender, a day laborer, traveled far and wide to find work. When he did find work, the pay usually wasn’t more than $2 a day for long hours of backbreaking work. Sometimes the payment never came. One job involved carrying coal in a pair of metal baskets hanging from a wooden yoke to a brickmaking kiln. He filled the baskets, hoisted the yoke of more than 100 pounds over his shoulders, and carried it up an incline and across a plateau where he emptied the baskets—in over 100-degree heat, his lungs filling with black coal dust. During harvests, he would work in the wheat fields, receiving one-eighth of whatever wheat he harvested as pay. The family’s main vegetables were assorted greens that grew around the village. Dal, India’s staple, was rare, as was any kind of fruit. “We eat what we can afford,” Shyamkali says.

Rajender struggles to support the family

Despite the 1,000-day efforts, Shyamkali’s daughter Anshika was underweight. By age 2 she was far below average, as were all of her sisters.

“I wish for her a good education and a good marriage. … If she is educated, she will get a good man.” —Anshika’s mother, Shyamkali

Nearing age 5, Anshika remains small for her age. She also has another sister, a final failed attempt for a boy.

Now it is time to join the movement and raise the clamor to end child and maternal malnutrition, wherever it may be. Creating a just and equitable food system that ensures everyone has access to proper nutrition is among our greatest—and most achievable—challenges. There is something each of us can do. Please use the following resources to get informed, get involved, and get going.

We can turn the tide on childhood malnutrition

TURN ON SOUND

She delivered a strong and healthy son, admired by relatives and neighbors for his robust and sturdy size.

They want hope in a world where malnutrition and stunting rob more than 1 in 5 children under the age of 5 of the opportunity to fulfill their human potential.

From Guatemala to Uganda to India—mothers everywhere crave knowledge on nutrition and health to give their children a better chance in life.

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The global cost is staggering:

Shyamkali - India

Brenda - Uganda

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Maria - Guatemala

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MARIA & JORGECHANGE CAN COME QUICKLY

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Sources: CIA World Factbook, 2020 Global Nutrition Report

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BRENDA & ARONNUTRITION CANNOT EXIST IN A VACUUM

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Many young moms considered themselves fortunate to have merely survived their own childhood. Many had routinely scurried through the bush like field mice to escape the terror of the warlord Joseph Kony and his gang called the Lord’s Resistance Army. The LRA aimed to topple the government and establish a theocratic state based on the Ten Commandments while breaking every one of them along the way: raping, murdering, stealing, pillaging, and abducting thousands of children to serve as soldiers and sex slaves. The years of LRA terror—and the brutality that also preceded it—still haunt northern Uganda. Since independence from British rule in 1962, Uganda endured a series of coups and conflicts and governments of kleptocrats, thugs, and murderers that scarred the country’s beauty and largely squandered its natural abundance. As the 20th century came to a close, the Pearl of Africa had become the Peril of Africa. One of the legacies of a half century of upheaval is widespread malnutrition and a woeful healthcare system that particularly jeopardizes the early years of life. Despite some big improvements beginning in the 1990s, Uganda remains among the countries with some of the worst outcomes in maternal and infant health.

A legacy of terror