Nairobi — From the scribble on the walls to mothers clutching crying babies, the bustling ward at Mbagathi District Hospital is unmistakable as the children's unit. But amidst the activity is a quiet problem -- newborns too weak to even whimper.
One of them is two-year-old Cynthia Akinyi, whose mother is struggling to stifle a cough as she explains to a nurse that her baby has had diarrhea for the last two days.
"What do you feed her?" enquires the nurse, who identified herself only as Josephine, as she writes in a logbook.
In her department, malnourished children are given micronutrients to treat deficiencies in vitamin A, iron, iodine and zinc - which may be a key factor in baby Cynthia's illness. Nearly a third of Kenyans are 'stunted' from lack of essential nutrients.
Without adequate nutrition from pregnancy through age two - the critical 1,000 days - infants suffer long-term health and economic consequences.
They are much more likely to die or be chronically sick, and their brains do not develop properly. They are, on average, nearly 20 percent less literate than those who have a nutritious diet, according to Save the Children.
High Cost of Undernutrition
In addition to the human toll, the economic cost to both families and nations is enormous. Undernutrition in childhood costs African economies as much as 16.5 percent of their gross domestic product, according to a series of studies of 12 countries being prepared by a consortium of international organizations.
A survey of hidden hunger, which was spearheaded by the nutrition think tank Sight and Life and published in the online journal PLOS ONE in June, showed that in most of the 20 countries with the highest index scores, more than 40 percent of children were estimated to be stunted and zinc-deficient, 30 percent were anemic due to iron deficiency, and half were vitamin-A deficient. In 36 countries, home to 90 percent of the world's stunted children, micronutrient deficiencies, especially vitamin A and zinc, were responsible for up to 12 percent of the total number of life-years lost due to ill-health, disability or early death.
Kenya ranked second in the world on the index. But one nutrition expert cautioned that old data could skew the rankings.
"It's mainly linked to the quality of the provided data that is available," said Dr. Klaus Kraemer, director of Sight and Life and co-author of The Global Hidden Hunger Indices and Maps: An Advocacy Tool for Action. "Not all of the surveys are from the same year. Countries need to do more about the assessments. I cannot tell you off the top of my head when Kenya did the last survey. It may be many years ago and we still have to include it."
Like many other global nutrition advocates, Dr. Kraemer emphasized the need for more, and improved, data on undernutrution worldwide, saying, "What gets measured gets done."
Micronutrient deficiency, or undernutrition, is linked to the quality of food that is being consumed, rather than how much. It is a problem that affects two billion people worldwide and in the last few years has gained considerably more attention than it has in the past.
At a nutrition summit in London in June, donors made over U.S.$3.5 billion in commitments to combat the problem between now and 2020. That means that funding on nutrition will effectively double from about $418 million to about $900 million a year during that period. The Children's Investment Fund Foundation, which co-hosted the summit with the governments of Brazil and the United Kingdom, pledged U.S.$787 million.
A year ago, a panel of economic experts published recommendations as part of the Copenhagen Consensus on the most cost-effective ways to allocate money to respond to the world's biggest challenges. Panelists said that for less than $700 million annually, it would be possible to eliminate vitamin A deficiencies in pre-school children, eliminate iodine deficiency globally and dramatically reduce maternal anemia during pregnancy.
Even in very poor countries, and using conservative assumptions, researchers determined that each dollar spent reducing chronic undernutrition has a 30-dollar payoff.
One of the interventions being used to fight undernutrition in Kenya and elsewhere is called "home fortification".
The strategy puts technology into the hands of caregivers, empowering them to improve the quality of their family's diet by adding micronutrients to the locally available foods they prepare at home. The process involves adding specialized ingredients such as multi-micronutrient powders, lipid-based nutrient supplements and other nutritious foods to the local meals that people eat every day.
Kenya rolls out home fortification through its National Nutrition Action Plan (NNAP), providing micronutrient supplements at selected clinics and elsewhere.
"We have taken this campaign to the home level," said Terrie Wefwafwa, the head of the nutrition division at the Ministry of Public Health and Sanitation. "We are using rural health centers to issue mothers with kits containing micronutrients for easy use at home."
She said health workers and mothers from the Coast and Lower Eastern regions have been trained and issued micronutrient powder. The Upper Eastern and North Eastern regions are next, she said.
Women aged 15 to 49 and children under the age of five are the main targeted groups, according to the NNAP, which began last year and extends until 2017. Not only does the plan target the stunted, wasted, anemic and underweight, it also aims to help women who suffer from malnutrition.
A September 2012 study that appeared in the Journal of Nutrition said that by working with children from lower eastern Kenya, a region that still struggles to achieve food security, the researchers sought to determine the success of enriching of food with micronutrients at the rural home level.
"The national fortification programmes may not reach every mother and child down in the village," explained Dr. Catherine Mutie, one of the study's authors. "We needed to find out if reaching this marginalized group could work by using fortified ingredients packed in specialized sachets."
Dr. Mutie said 40 percent of the children under five were anemic while a third of them had iron deficiencies when the research began. But after four months of feeding, the children with maize porridge enriched with micronutrient powder, anemia reduced by about 46 percent while iron deficiency decreased by about 70 percent among the study group.
"This is a very critical area of reaching that child in the village who may not be accessing the mass fortified foods," Dr. Mutie said. "It deals with food at the point of consumption where one can add micronutrient powder, mix it and then consume the meal as a whole."
Dr. Kraemer noted that Kenya had been working hard to improve nutrition in recent years. "National [micronutrient] fortification was mandated last year for flour and maize meal, and oil, which will certainly make a significant impact over time," he said.
Need to Scale Up Interventions
Yet, despite the availability of relatively simple and extremely cost-effective interventions to address malnutrition, few countries effectively implement these proven tools at scale.
"Taking micronutrient interventions to scale requires different approaches, it requires distribution to the poorest, or the poorest receiving vouchers so they can get it somewhere and it requires that the product is in local markets so it is distributed through market-based approaches," Dr. Kraemer said.
There are also quality assurance and quality control issues, which are among the main challenges that nutritionists cite in trying to provide sufficient micronutrient supplementation and fortification to those who lack it in developing countries such as Kenya.
This is one reason why consumer protection groups, such as the Consumer Federation of Kenya, are not convinced of the efficacy of fortification.
Skeptics think it's a ploy to create business opportunities for corporations, that it will undermine the consumption of traditional staple foods, or that it is a scheme to sneak genetically modified foods into households.
"Our history is littered with suspicion for new things because of lack of awareness," said Nick Hutchinson, chair of the Kenya National Food Fortification Alliance (KNFFA). "It has been challenged all over the world by lobbyists who are committed to pure food."
But, he said, since not all foods have sufficient nutrients, it is necessary to give the consumer a wider choice. "You shouldn't try to bring a new product into a country without experiences by the population," Dr. Kraemer said. "They need to know it, and also if there is some kind of [food] emergency it is much more appropriate that these kind of products are locally available and locally produced."