Pakistan’s learning crisis starts in the womb

Assad Ahmad links stunting and how our kids do in school

Pakistan’s learning crisis starts in the womb
Every year, the good folks at Idara-e-Taleem-O-Agahi release their Annual Status of Education Report (ASER) to considerable fanfare. This report is a fantastic piece of work, of the sort that is vital for informed discourse. As its name promises, every year, the report takes a deep, hard look at where Pakistan stands on enrolment and learning outcomes.

And every year, there is much soul searching, as we wonder why around half of our fifth graders can’t read stories (in any language) designed for second graders, or perform long division. The policy prescriptions that inevitably follow, tend not to look at the half of the children who CAN read, and wonder how they managed to learn if the system is so badly broken. Instead, the suggestions start from a blank slate and range from the revolutionary (read: impossible) to the exact opposite (e.g. suggesting things that are already being done). Double the budget, they cry! Hire more teachers! Raise teacher’s salaries! Start teaching in English! Stop teaching in English! Build more schools! Don’t waste money on more bricks and mortar! The one prescription that never seems to emerge, or, at any rate, get heard, may be the one with the biggest bang for the education buck – focus on maternal and infant nutrition.

This is a bizarre omission.

Thanks to poor maternal and infant nutrition, 45% of Pakistani children under the age of 5 are stunted. What this means, in plain-speak, is that their growth is significantly below child growth standards. This is the highest stunting rate in South Asia, and one of the highest in the world.  This statistic is well-known, even if what it means is less understood. The WHO defines stunting as a height of 2 standard deviations below the optimal level for each age. To illustrate, for a two-year old girl, for whom the WHO standard height is 86cm, anything sub 80cm would indicate stunting. For boys of the same age, the standard, and the stunting threshold, is 2 cm higher. It is also well established that childhood stunting has a severe and, to a large extent, irreversible, impact on mental development and cognition. The “first thousand days”, starting from conception, are widely acknowledged to be the critical window during which a child’s malnutrition must be tackled to avoid permanent damage.

So, we know at least half of our primary-school age kids are either not in school, or in school and not learning much. We also know that around half of our kids were so poorly nourished between conception and the age of 2, that their physical and mental development is below globally accepted standards. Would it be a giant leap to assume that one may be contributing to the other?

To know what to make of this, we must understand three things: First, the evidence we have linking nutrition with mental development and learning; secondly, why the prevalence of stunting has barely budged, even as poverty rates have plummeted; and finally, what can be done to solve the problem.

First, the evidence.

The motherlode goes back to a large-scale randomized trial conducted from 1969 to 1977, across four Guatemalan villages. The trial focused on comparing the development of two random sets of Guatemalan children from conception onwards. One set of children (and pregnant mothers) had their regular meals supplemented with a nutritious, protein heavy drink (with about the same caloric value as a Coca Cola), twice daily. The other set, unluckily for them, was administered a placebo – a sweet, cool drink with far less nutritional value. The primary observations focused on those children who had been exposed to the trial for only their first three years. Nearly 200 research papers, published over 40 years, have been based on data collected as the exposed children grew into adulthood.

The results include some stunning findings. As much as thirty years after the trial ended, men who had received the nutritious supplement as infants, were earning an average of 46% higher hourly wages than those who had received the placebo. When tested as adults, women who had received the nutritious supplement scored over 30% higher on reading comprehension tests than the placebo group.

Similar studies and policy measures, have yielded similar outcomes around the world, both in terms of years kids spend in school, and what they learn while they are there.  The WHO, in its “Stunting Policy Brief”, cites similar studies in India, and South Africa, that found stunting at the age of two led to one less year of schooling on average. Studies from the Philippines to Jamaica all show significantly higher average reading, reasoning and IQ test scores for non-stunted vs. stunted children.

The clincher though, for the argument that the answer to our learning problem could be staring us right in the face, is a widely cited 2007 Lancet study exploring the impact of stunting in developing countries. This study combines the impact of less school attendance for stunted children worldwide (controlling for poverty), with the impact of reduced learning while in school, due to lessened mental abilities. It then states the impact as a single number -  the total learning deficit in grade equivalents. At just shy of 3 years, it’s an absolute shocker.

It is so shocking that it needs to be stated again, in a different way. If the average well-developed child in a poor country attends school for, say, 6 years, then the average stunted child likely attends school for 5 years. In that time, the stunted child learns the equivalent of what the well-developed child would be expected to learn in around 3 years.

Is it still surprising that half of our 5th graders can’t read a 2nd grade text?

So, why is stunting so prevalent in Pakistan? Why is it substantially higher than what is experienced by countries with similar income levels?

The answers to these questions are fairly well-known, and needn’t be fully rehashed here. The World Bank’s November 2016 Pakistan Development Update has an entire section devoted to answering them. In a nutshell, the proximate causes for stunting include: early and frequent pregnancies, poor maternal nutrition (the WHO believes this is 20% of the problem – hence, the headline of this essay), poor breast-feeding practices (in turn, partly related to poor maternal nutrition), poor sanitation (leading to disease, which has the same impact as poor nutrition), and of course, a poor supplementary diet for infants. Interestingly, the World Bank cites a wide body of research that suggests only a very weak link between food availability and nutrition outcomes. This is why economic growth, and the accompanying reduction in poverty, have barely put a dent in Pakistan’s stunting rate. The underlying issues - poor awareness, gender inequality (evident in food consumption patterns), and inadequate policy (e.g. not fortifying food staples with crucial micronutrients) – must be directly addressed, rather than left to market forces.

Clearly, some of these issues constitute “low-hanging fruit”, whereas others, like resolving the sanitation problem, or convincing women to wait longer before having children, are far easier said than done. A good starting point for policy makers looking for some of the easier fixes, would be to study the case of Maharashtra, which reduced the incidence of stunting from 44% to 23% in just 6 years (2006-12), primarily through leadership focus, advocacy, and training programs, to raise awareness of better nutrition practices. In the Pakistani context, priority problems to target using these tools might include the low rate of early breast-feeding (18%), low awareness of the link between maternal nutrition and the long-term success and productivity of offspring, and low awareness of the impact of poor hygiene. These may best be tackled by a combination of appropriate behavioural nudges through radio and television, along with health worker training. In tandem with this, programs to fortify food staples and vegetable oil with important micronutrients and iron, will have to be a key prong of any nutrition strategy. This would be similar to the iodized salt programs of days past.  Again, these solutions are widely known, what is needed is advocacy and leadership – increasing awareness of the link with education outcomes may act as a powerful catalyst for change.

The timing for action on this link is ripe. While education budgets have seen large increases in the past several years, and there is tremendous focus on poor learning outcomes, nutrition has been far from the limelight. This is beginning to change, but very slowly.  In the past few years, mainly led by donor interest, there has been an increase in nutrition related activity. Despite this, the scale of activities aimed at the critical “thousand-day window” in which stunting can be effectively combatted, is woefully inadequate. This is especially true in Baluchistan, where the stunting rate is highest (and federal intervention is warranted). Sindh, the second most stunted province, has (with WB assistance) just embarked on a 5 year, $90 million a year, program aimed at reducing stunting by 1% a year over the next 5 years. This is not nearly ambitious enough. FATA, with a 58% stunting rate is a disaster of epic proportions. Perhaps ironically, the only meaningful anti-stunting project in the tribal areas is a USAID initiative.

Studies referred to by the World Bank estimate that every dollar spent on key nutrition interventions in Pakistan can generate a $30 economic return. In an environment where there is tremendous competition amongst development priorities, this number is important to remember. This is, of course, aside from the unquantifiable cost of literally hundreds of thousands of child deaths attributed to poor nutrition.  Those who care about our children, and their education, would do well to listen up. In the current circumstances, asking for nutrition programs may, on the margin, improve learning outcomes more than direct increases in education spending. And that’s something worth educating people about.

The writer is a Lahore based columnist and consultant. He has previously served as a director at a major European investment bank. He has also worked as management consultant at a leading global consulting firm, where he participated in an extensive social sector delivery initiative led by the Government of the Punjab. The views expressed are entirely his own. He tweets @assadahmad