Stunting in Uganda

Here's another term paper I just wrote:

Kelly Moltzen
Final Paper
E33.2314: International Health and Development
December 17, 2008

Political, Social, and Economic Contributors to Stunting in Uganda

The prevalence of stunted growth in Eastern Africa due to undernutrition is the highest in the world and has serious implications for maternal and child health (Black et al., 2008). In Uganda, where nearly half (49%) of the population is under the age of 15 (Bachou & Labadarios, 2002), the national average of stunting in children younger than five years old is 32% (UNICEF, 2008). Prevalence of stunting is generally highest for the poorest segments of the population (Black et al., 2008), with this number reaching up to 54% in the war-torn northeastern region of Karamoja (Africa News, 2007a). Stunting is associated with higher mortality and lower cognitive development. It therefore has widespread implications not just for an individual’s development, but also for the development of entire regions (Jilcott, Masso, Ickes, Myhre, & Myhre, 2007). Stunting has been found to be the best predictor of human capital, as “there is compelling evidence that malnourished children are unproductive as adults” (Africa News, 2008). Therefore, the prevention of stunting has the potential to bring about “important health, educational, and economic benefits” (Victora et al., 2008). The underlying causes of maternal and child mortality include poorly resourced health and nutrition services, food insecurity, and inadequate feeding practices, inadequate access to safe water and sanitation (UNICEF, 2008). However, there are even more basic social, economic, and political causes that contribute to the lack of capital necessary to prevent these underlying causes (Black et al., 2008). In Uganda, these include poverty, political unrest, misplaced policy decisions and interventions, and the discrimination and exclusion of mothers and children.

Stunting is defined as height-for-age less than -2 z-scores (Jilcott et al., 2007); the average Ugandan child falls one standard deviation below the international norms (Alderman, 2007). This restriction of a child’s potential growth is evidence of chronic undernutrition, leads to irreversible impairment, is associated with increased risk of death, and could potentially affect future generations. For instance, maternal short stature adversely affects pregnancy outcomes (Black et al., 2008). Research shows that it is much more efficient to prevent chronic undernutrition and its devastating effects than to attempt interventions later on in the lifecourse (Africa News, 2008), as the critical period of development occurs during the first two years of life. However, the Ministry of Health in Uganda has historically focused its childhood nutrition programs on children who are already underweight (Africa News, 2008), a misdirected intervention that has had serious consequences.

Northern Uganda is burdened with great deals of civil strife. Political instability in Uganda is associated with increased contributory factors to malnutrition, poor economic growth, worse health service delivery by government, local, and international agencies, and higher child mortality rates, as compared to times in the country’s history that saw more political stability. In a study of the Bundibugyo District of Uganda, where the stunting rate in children is 44.8%, students ranked last in recent secondary school standardized leaving exams (Jilcott et al., 2007). This rural, marginalized population is still recovering from Allied Democratic Force rebel attacks that occurred in the late 1990’s, during which people had to live in Internally Displaced People (IDP) camps. Malnutrition, malaria, tuberculosis, and sickle cell disease are common among children in Bundibugyo (Jilcott et al., 2007).

Social aspects such as gender inequality play a large role in health and stunting rates in Uganda. In a country where many families already struggle to get a meal on the table, women and children traditionally eat last in the household, after men (Nadakavukaren, 2006). “To reverse the trend of gender inequality, the United Nations Children’s Fund (UNICEF) recommends the empowering of women in politics, arguing this has the potential to change society” (Africa News, 2007c; UNICEF, 2008). UNICEF’s State of the World’s Children 2007 report said “women who have greater influence in decision-making can promote better healthcare practices for the family. Women's participation in household decisions decreases stunting among children and reduces child mortality” (Africa News, 2007c).

The impact of poverty in Uganda is profoundly felt through a lack of funds and resources to buy livestock. “Animal-source foods…are an important component of children’s diets, as a major source of protein and micronutrients” (Black et al., 2008). Yet in Uganda, many families can only afford meat once a year, if that (Tuller, 2007). This excludes them from access to adequate sources of protein and iron in the diet – key nutrients in preventing maternal and child mortality. Low intake of meat, fish, and/or poultry is associated with iron-deficiency anemia in mothers, which is an important contributor to maternal mortality as it increases the risk of dying with blood loss during delivery (Black et al., 2008). Mothers who die while the child is still an infant poses additional risks for newborns, as they no longer have their mothers to breastfeed them. Grandparents, particularly grandmothers, are left to care for 50% of orphans in Uganda (Africa News, 2007c); however, milk production of grandmothers is not nearly as sufficient as would be necessary for the child to thrive. If women were empowered within the household and within the government, they could push for better access to livestock which could drastically improve the nutritional and economic situations of many Ugandans.

The importance of farming and agriculture to nutritional status, as well as the social and economic development of Uganda, cannot be overstated. Farming is a critical aspect of the economy of Uganda; one women professed that “African business is agriculture” (Stuart, 2007). However, the current cropping systems in Uganda are leading to nutritional deficiencies and are also threatened by climate change. Uganda would do well to consider alternative agricultural strategies; over the past few years, the National Academies released a series of books entitled “The Lost Crops of Africa,” which enforces the promise of many crops that are native to Africa, but are not currently widely harvested (The National Academies Press, 2006).

There are currently two main cropping systems in Uganda: a grain-based system in the northern and western regions, and a banana-based one in the central, southern, and eastern regions (McIntyre, Bouldin, Urey, & Kizito, 2001). Since livestock farming is not a large contributor to nutrient intake in Uganda, this leads to low protein intake in the banana farming areas, as the banana-based system has been found to be associated with nutritional deficits of protein in addition to calcium, iron, and zinc. Zinc deficiency is associated with stunting prevalence, and both iron and zinc deficiencies have both been shown to be associated with increased cognitive impairment among children (Black et al., 2008). A different study found that the local variety of bananas is low in iron, iodine, and Vitamin A (Eliot, 2008) – the three micronutrients that are most deficient in Ugandans’ diets (Bachou & Labadarios, 2002).

In addition, diminished crop yields due to seasonal variation and crop infestation compromises the nutritional quality of bananas (Stuart, 2007). Addressing banana stem infestations is one solution, as weevil and nematode infestations in the roots of banana plants lead to a decreased absorbance of vitamins, minerals, and water by the plant (Stuart, 2007). Drought and soil degradation may compound the effects of the diseased stems, leading to lower yields and quality of bananas. Using tissue-cultured banana plants with endophytes (good microbes) reintroduced to the plant at an early stage would help to increase the plant’s natural defenses before it is planted in the field. A sensitization campaign was supposedly started in 2008 to educate Ugandans on the adoption of growing tissue-cultured banana plants – something that has already been started in Kenya (Stuart, 2007). Another potential solution is genetically modified bananas, which have been developed in Australia and are currently undergoing field testing in Uganda (Eliot, 2008).

Strategies have also been proposed to alter the land area’s crop selection. Initiatives which set out to introduce new crops to farmers and broaden the range of crops planted may hold promise in improving the diet quality of Ugandans; the Uganda Bean Program is one such example of success (McIntyre et al., 2001). The Vice President of Uganda discusses the role of maize flour in the diet as contributing to stunting, as its high phytate content contributes to zinc malabsorption, and “zinc deficiency contributes significantly to stunting and impaired cognitive development” (Africa News, 2007b). He offers the suggestion of providing children with more “millet, soya, and sorghum, which are easily available in Uganda” (Africa News, 2007b). The Ugandan government could be instrumental in providing aid to the development and implementation of alternative agricultural strategies, as well as facilitating the distribution of higher nutritional quality food.

Agriculture is inextricably linked with the HIV/AIDS epidemic, as the practice makes available food and nutrition that are of critical importance in fighting the disease (Africa News, 2008; Tuller, 2007). David Tuller, a graduate student from the University of California, San Francisco, spent five months in Uganda investigating whether “food insecurity…undermines the effectiveness of HIV treatment” (Tuller, 2007). Far too often, parents must choose between feeding their children and selling their crops to make the money needed for the “monthly clinic trip for the medication that keeps them alive” – a trip that also means a missed opportunity for gardening or other work (Tuller, 2007). Compounding the issue of food insecurity among people with HIV/AIDS is the issue of power struggles between men and women. Hunger and food insecurity put women at the mercy of their husbands, who will oftentimes demand unprotected sex in exchange for bringing food home (Tuller, 2007). In this way poverty, food insecurity, and gender disparities interact to prolong the HIV epidemic and continue the plight of the disenfranchised.

The government has a role to play in improving food security in urbanized areas as well. Although stunting is twice as prevalent in rural areas as urban ones, people are moving to urban slums in greater numbers, leading to higher rates of stunting in urban areas (Bachou & Labadarios, 2002). Malnutrition in urban areas is a very real issue, but strategies such as urban agriculture could help curb food insecurity. Urban agriculture has traditionally formed an informal safety net for buffering the impact of economic hardship and the cutbacks of urban subsidies and formal safety nets. However, urban farming is currently not endorsed by the government and is actually illegal, despite its positive association with decreased rates of stunting (Maxwell, Levin, & Csete, 1998). Officials of local and national governments do not recognize benefits that urban farming could have on health; they actually consider it a threat to public health and generally overlook or even discourage it (Maxwell et al., 1998). There is plenty of idle land available in cities that could easily be used for urban farming if policymakers recognized its importance in enhancing food security and made the legal framework more conducive to informal livelihood strategies.

Perhaps the most important thing the government could do to increase food security and improve its country’s maternal and child health is to form community partnerships (UNICEF, 2008). Engaging the community in the promotion of its own health is critical to the success of any intervention, as it builds capacity and empowers its members. Governments should engage in intersectoral collaboration and work cooperatively on community, district, and national levels to include all members of a community in policy and decision-making processes, particularly women. By including women in policy and decision-making, this may help change the ethos of gender discrimination and ultimately lead to improved diets and access to healthy environments for women and children. As UNICEF posits, “the ultimate responsibility for ensuring children’s rights to health and nutrition lies with national governments in partnership with civil society” (UNICEF, 2008).

Local authorities, research establishments, and development agencies should “work with the urban poor to understand and develop other urban food and livelihood security strategies” (Maxwell et al., 1998). A key facet of community partnerships involves community growth promotion, or the recruitment of community health workers to bring health education to the communities door-to-door. This may include educating caregivers on the importance of exclusive breastfeeding, health, nutrition, numeracy, and literacy, and improving the capacity of women in a community to recognize malnutrition (Alderman, 2007). Rates of exclusive breastfeeding are declining throughout the world, which is problematic because there is a higher risk of morbidity and mortality from suboptimum breastfeeding (Black et al., 2008). Similarly, “suboptimum complementary feeding is clearly a determinant of stunting” (Black et al., 2008). Infectious diseases, particularly those that result in diarrhea, reduce intestinal absorption of nutrients and thereby are large contributors to stunting (Black et al., 2008). Educating women on these health issues could not only lead to lower stunting rates and improved health outcomes for children, but could also improve capacity, decrease dependence, and even improve the economy.

Farming and community growth promotion are both associated with decreased prevalence of stunting in children. One study found significantly less stunting in children from farming households than children from non-farming households (Maxwell et al., 1998). Also, there are more moderately and severely undernourished children in non-farming households than in farming households among lower socio-economic households (Maxwell et al., 1998). Farming has been proposed as a good female income-generating activity, and allows mothers to spend more time caring for their children (Maxwell et al., 1998). Evidence shows that community growth promotion, including education and skills training on early childhood development, can have an impact on children’s diets in Uganda. In a longitudinal intervention study, training focused on breastfeeding, complementary feeding at time of weaning, and diet diversification (Alderman, 2007). Improvements were seen in children’s diets in their first year or two of life with long-term intervention exposure, which is significant because the first two years of life are the most critical in a child’s physical and cognitive development (Africa News, 2008).

In the north, political upheaval compromises the social capital and economic potential of certain populations residing in Uganda, making self-sufficiency more difficult. Rebel groups in northern Uganda pose a serious threat to the health and well-being of the population. Northern Uganda is plagued by the Lord’s Resistance Army’s terrorist activities, which makes access to food difficult and takes children out of school. This is especially true in Karamoja, where fewer than twenty percent of children attend school because they must help out with the farming at home (Grainger, 2007). To make matters worse, droughts are drastically reducing the amount of crops to harvest, and two-thirds of the region is dependent on foreign food aid such as from the World Food Programme (Africa News, 2007a; Grainger, 2007).

In addition, northern Uganda is home to a significant number of refugees relocating to Uganda from neighboring countries. In 2005, there were nearly 188,000 refugees in Uganda from Sudan alone (Kaiser, 2005). Although the majority of refugees currently in Uganda have been there since the 1980’s and 1990’s, the government of Uganda has outright rejected the notion for permanent integration of refugees into the Ugandan population (Kaiser, 2005). Yet refugees are not even granted the right to freedom of movement, and experience insecurity, deprivation, and political repression in the north (Kaiser, 2005).

Refugees in Uganda have consistently been the victims of social exclusion, defined by Manuel Castells as “the process by which certain individuals and groups are systemically barred from access to positions that would enable them to an autonomous livelihood within the social standards framed by institutions and values in a given context” (Castells, 2000). The Ugandan government has attempted to implement the “Self-Reliance Strategy” (SRS) to provide services to refugees in such a way that it would improve the socioeconomic development of both the refugees and their Ugandan hosts. The idea was for services for refugees to be integrated into regular government structures and policies. It was envisioned that refugees would be able to grow or buy their own food, access and pay for basic services, and maintain self-sustaining community structures (Kaiser, 2005). While the SRS program was successful in one region that had considerable political stability, in most other areas refugees were often relocated from one unsafe area to another, not informed of what was going on, and regularly denied access to a range of economic activities. In attempting to fulfill the material needs of the refugee population, their legal and political rights have not been maintained. As a result of this social exclusion, the building of capacity, self-esteem, and social resources has been hindered, consequently undermining the goals of the program (Kaiser, 2005). This has implications for nutrition outcomes in that the crux of a successful, sustainable public health intervention relies on a community’s social capital and solidarity.

There is much evidence of the negative impact of political activities on nutritional status. Granaries have been abandoned in the north due to increased political insecurity, which adds to the problem of recurrent drought and seasonal variation that threaten household food security (Bachou & Labadarios, 2002). Political insecurity has also made the delivery of health-promotion services in these areas more difficult (Bachou & Labadarios, 2002). There was a statistical difference in stunting prevalence in sub-counties depending on distance to the health center, with populations who lived further away experiencing greater rates of stunting (Jilcott et al., 2007). This underlines the significance of lack of access to health-promoting resources, as management of malnutrition is primarily facility-based in Uganda (Jilcott et al., 2007). In addition, for those in the areas with the worst malnutrition, such as Karamoja, the health and therapeutic feeding centers are regularly overcrowded, which raises the risk of cross-infections and hypothermia from sleeping on the floor (Africa News, 2007a). Indeed, as UNICEF puts it, “cultural and climatic factors as well as endemic conflict combine to create cyclic humanitarian crises of a disastrous scale and complexity” (Africa News, 2007a).

While the intentions of programs such as the SRS are noteworthy, their implementation and outcomes have not been quite as stellar. The government must be sure to be sensitive to the realities of life when developing intervention programs. It must balance its own interests with its citizens, and those of the refugees in the north, in order to mitigate the detrimental effects of conflict on both populations. Chen and Berlinguer state that “good health is the cornerstone of economic progress, a multiplier of society’s human resources, and, indeed, the primary objective of development” (Chen & Berlinguer, 2001). Therefore, vesting more interest in the rights of refugees in terms of the SRS would allow these individuals more autonomy and access to health-promoting resources, ultimately benefitting the country of Uganda as a whole.

One intervention that has been moderately successful but has encountered some difficulties is the distribution of Vitamin A supplements. Vitamin A deficiencies have been common in Uganda, and while the vitamin is fat-soluble, Ugandans’ main source of Vitamin A is green leafy vegetables (Bachou & Labadarios, 2002). Ugandans’ diets are low in fat, especially as a result of the insufficient contribution of animal sources to their diet. Inadequate quantities of Vitamin A in mothers’ diets lead to Vitamin A deficient breastmilk (Black et al., 2008). The Ministry of Health’s national protocol for Vitamin A supplementation for postpartum mothers has been moderately successful at reducing Vitamin A deficiencies in Uganda, with a current coverage rate of 78% in children 6-59 months old (UNICEF, 2008). However, there are many barriers to the success of supplement distribution in Uganda. The country lacks a well-defined system for the distribution of the capsules, as they are only readily accessible to mothers who use health facilities (Bachou & Labadarios, 2002). In addition, capsule supplementation may not be ideal in the north due to the political instability, and in many of the isolated, rural areas of the country, as serious barriers may be encountered in attempting to distribute supplements to both of these populations. Additionally, supplementation is not a sustainable solution, but a downstream intervention that does not get to the root of the problem of inadequate Vitamin A in the food that is consumed. Micronutrient supplementation may be successful in improving child health outcomes in the short term, but in order to “eliminate stunting in the longer term, these interventions should be supplemented by improvements in the underlying determinants of undernutrition, such as poverty, poor education, disease burden, and lack of women's empowerment” (Bhutta et al., 2008).

Community partnerships have proven successful in decreasing rates of stunting in India (UNICEF, 2008), and will likewise be critical to successful public health interventions as Uganda moves forward. The government’s first priority should be inclusion of women in decision and policymaking, and building intersectoral collaboration. These collaborations should then prioritize nutrition issues, improving food security in Uganda such as through supporting alternative cropping strategies and changing its stance on urban agriculture. At the same time, it should support education on breastfeeding and complementary feeding practices through community growth promotion. In the Lancet’s 2008 series on Maternal and Child Undernutrition, Bhutta et. al concluded that “in populations with sufficient food, education about complementary feeding increased height-for-age Z score by 0.25…, whereas provision of food supplements (with or without education) in populations with insufficient food increased the height-for-age Z score by 0.41” (Bhutta et al., 2008). Stunting is inextricably tied to social, economic and political issues, so in order to decrease its prevalence, improve maternal and child health, and improve the future development of Uganda, the role of policy and community partnerships should be seriously considered.

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