"STUNTING OF CHILDREN UNDER THE AGE OF 5 yrs IN TANZANIA Prevention is better than cure. This adage is as old as history itself and is as true today as it has ever been. But how many of us heed its wisdom? This wise proverb is applicable in all situations whether it is in family relationship, communities, governments or between one countrys relationships with another. Often times it is used in prevention of diseases. The quote below sets the stage for this article. The future of Africa lies with the well-being of its children and youth Todays investment in children is tomorrows peace, stability, security, democracy and sustainable development. ~ The African Union 2007a Stunting in children below the age of 5 years is a major health burden in most developing countries and it is estimated that over 140 million children are affected in these countries. Numerous studies have been conducted across the developing world and especially in Africa on the subject of stunting. Causes of stunting are multifactorial but include nutritional deficiencies, including lack of micronutrients, as a result of poverty or lack of awareness or uniformed parents, and numerous studies have established a close relationship between stunting and frequent episodes of enteric diseases (Giardia lamblia, Escherichia Coli and other types of pathogens) causing diarrhoeal diseases. Recent studies have also shown that on the average a child below 5 years in the developing world experiences three episodes of diarrhoea per year. It has to be understood also that children who are subjected to these nutritional deficiencies are prone to fall prey to other numerous tropical diseases such as malaria, which is more severe, respiratory tract infections and many others due to reduced immunity. It will be seen that reducing stunting in the African child therefore, is a major and a multipronged undertaking that should include alleviating poverty, provide clean water supply, improve sanitation, nutritional health education, improve health prevention and curative services, family planning, improve educational system and massive mobilization of resources to improve the living standard of the communities especially in the rural and peri-urban settings. Improved governance and rapid economic progress are essential prerequisites to a favourable environment for our childrens upbringing and well being. A Demographic Health Survey report conducted by the Government of Tanzania in 2004 showed that 38% of children under the age of 5 years are stunted and 13% are severely stunted. In other words 51% (or if you like 38%) of Tanzanian children in 2004, and may be in the later years, are stunted to a variable degree. Below is the website link to the report. www.measuredhs.com-pubs-pdf-FR173-TZ04-05.pdf Stunting is most pronounced between the ages of one to two years. Stunted development and growth is global in the sense that it affects all organs including the brain. Development of body organs takes place almost fully between birth and eight years of a childs growth. One therefore speculates the effects of retarded growth of body organs such as the brain, endocrine system, immune system, cardiovascular system and all the other systems that may have long term effect on the child and later in adult life. It is now being speculated that there is a strong relationship between childhood stunting and cardiovascular diseases in children at the ages of 14 to 15 and also a strong correlation to future communicable as well as non-communicable diseases such as diabetes mellitus, obesity, hypertension and others. Researches are in progress to identify the long term effects of stunting in the African child. Stunting resulting from poor nutritional status of the majority of our children in Tanzania may be impacting negatively in the overall performance of our youths. Personally, I have been a practicing physician in Tanzania for over 40 years before my final retirement. This includes the years I spent working in the public health sector in several districts and regions in Tanzania early in my carrier. During the whole of my carrier, I witnessed countless young children who lived and grew up in rural and peri-urban poor settings receiving deficient nutritive diet throughout their lives course beginning in the peri-natal period (immediately before and after birth) and extending into early childhood, onwards till leaving home, where the child continued to receive the same poor nutritive diet throughout primary schooling and young adulthood. Malnutrition was rampant in many of these areas. To compound this depressing scenario these children were also subjected to frequent episodes of malaria, diarrheal diseases, respiratory infections and intestinal worm infestation which debilitated them further. This is in part due to an uncoordinated and/or underfinanced strategy that links peri-natal, antenatal and early childhood care within the household, local health facility, and primary schools system. It should be noted that the international community also defines stunting as beyond physical appearances such as height and weight. Thus a stunted child most likely infers that the childs body organs are inhibited in their normal growth. Thorndike Barnhart World Book Dictionary defines Stunted as 1. Checked in growth or development; undevelopment; dwarfed; 2. Disproportionately or abnormally short or small; 3. (of growth or development) checked or arrested. The Oxford Advanced Learners Dictionary defines Stunted as prevent from growing or developing properly. Definitions of stunting are many but basically it means retarded normal physical growth and cognitive development. It is known and accepted that brain growth of a child in terms of learning new things and acquisition of general knowledge is maximal between conception and eight years. This is the period when the majority of Tanzanian children are deprived of essential nutritive and micronutritive elements and the child is subjected to an array of diseases. If these assumptions are valid, will we be right to assume that if a child remains stunted during all his/her formative years of between one and say eight years when the child is in standard one that the performance of this child in school will be below par? This assumption of retarded body and specifically brain development does not necessarily mean all these children are cognitively impaired and will be unable to learn anything. This is not so, since the severity of stunting varies between different individuals and with adequate teaching in schools a compensatory catching up mechanism facilitates childrens acquisition of knowledge. However, one may ask a rhetorical question that if all our children were to receive sufficient nutritive diet during all their formative years and the family environment were conducive for growth and development, what would be the state of our childrens growth and development and ultimately performance in school and as adults in society? As you read the referenced Tanzania Demographic Health Survey Report of 2004, you may want to ask yourself if this finding of stunted children is fixed during the period of 2004 or does it extend backwards for several years. How far back has stunting been going on and is it also extending forward? Taking this argument further for discussion and action on the subject, my speculation on the issue is based on the assumption that if 51% of us in Tanzania were exposed to a deficient nutritive diet and ended up stunted, would we be right in assuming that as adults some 51% of us are stunted to some degree? Of course as I mentioned earlier, a percentage of these children will go through a compensatory mechanism and catch up, but what are the implications to our country if a certain percentage of adults were affected by stunted growth and development? Clearly, the effects of stunting are not limited to children but to the overall health and productivity of our society. How many future doctors, lawyers, school teachers, politicians and others will never have an opportunity to fully reach their potential? This is the true tragedy facing our country and Africa today in addition to many other debilitating health hazards. In the early 1950s when I was in primary school at Mpwapwa, the school had a routine supplementary feeding programme. Porridge for breakfast was always mixed with milk from the school dairy farm or supplemented by milk from Mpwapwa Veterinary Centre. In addition all children from standard V to standard VII were provided weekly with one kilogram of milk powder and half a litre of palm oil and all students were encouraged to have small horticultural plots where we grew tomatoes, carrots, salads and others vegetables for personal consumption. It is possible some other schools in Tanganyika then had a similar programme. I am not sure for how long this supplementation continued. Looking back later in my life I realized how wise our leaders were then to help all their students to catch up in their development. In 1978 when President Moi of Kenya came to power, he started a milk for all children programme. Every Kenyan child was provided with milk to prevent nutritional deficiency, for free. He stated then that this would help raise brighter and smarter society for the future of Kenya. The milk drinking culture has remained in Kenya until today; Kenya being one of the highest milk consuming and producing societies in East African region. The Moi Milk Kids are todays Kenyan young adults in their 30s and 40s who have since helped propel Kenya to one of an emerging economic giant in Africa. This article may seem to be a little unfair to the uninformed or poor families by supposing that the responsibility should squarely be shouldered by them. If the parents or households are in poverty what incentive if any will there be to improve ones station if there is a feeling of hopelessness and immobility coupled with low self-awareness at the community level? The question remains how can the stunting problem be linked to existing/standard Maternal-Neonatal-Child-Health (MNCH) and educational services (including adult education) in Tanzania to leverage existing service to cope with the problem? Additionally, what are the key stakeholders (Public, Private and Faith-based, medical and non-medical) that can be involved to create more accountability at the community and household levels? How can the compulsory primary school education be strengthened to include student and teacher accountability, provide healthy nutritional meals or snacks, eliminate or re-organise vendors surrounding schools to re-stock inventory from chips, soda, sweets and ice-cream to include fruits, milk and other healthy dietary snacks. Shouldnt the Government institute immediately school milk programmes or a healthy meal once a day at all schools? Many of students going to schools go with an empty stomach. This state of affairs is not conducive to learning. Two stakeholders that play a significant part in the status quo are Non-governmental organisation (NGO) and academic research institutions. There have been numerous academic publications on stunting, vitamin supplementation and nutrition that provide enough evidence that could translate into informed policy. However, often times academic research falls short from policy because the incentives and follow-up funding are not in place. Many of the studies while extremely important tend to serve individual academic careers. Translation of results and community education has little bearing on an individuals promotion or reward system. In fact translational activities often serve as a time deterrent to getting the next paper published that is the primary centre piece to academic success. However, with all the research material that is available that could be translated into policy, modern communication technologies and improved access to low cost nutritional supplementation we can make necessary changes to ensure the health of our nations children. Some modest suggestions include: a)Public, faith based and private health sectors work together to define minimum quality standards for health centers, suppliers, health workers, and households for reducing stunting and improve nutritional education within existing maternal neonatal and child health (MNCH) services. b)Public, faith based, and private schools are evaluated for the current standard of nutritional and health safety education as well as access to healthy snacks and meals during pupil attendance. Reduce the number of vendors that sell only chips and soda outside the primary schools. Coordinate community parent organizations to demand that alternative healthy food sources are provided either at the school or in the surrounding community. c)Strengthen research translation unit both at National Institute of Medical Research (NIMR) and other public and private teaching hospitals to set criteria for academic research that creates incentives for translation of results into the community. d)Establish an independent Tanzanian Ombudsman office that provides advocacy and support for local partners to monitor the progress and intended outcomes of studies with NGO partnerships. Government action is needed urgently now to address this tragedy facing Tanzanian children and our future in order to fulfill the African Union call stated at the beginning of this article. Dr. S. M. A. Hashim firstname.lastname@example.org 14th September, 2009.