Well, just like that, June is coming to an end and so is my internship. You’ll recall that I spent my spring and summer Working from Home with the World Bank. During my practicum I performed a literature review of several low- and middle-income country’s health care systems and how they are working towards universal health care for all and incorporating nutrition services within these models. There are a multitude of learnings and moments of insight I could expound on, but I’ll focus on Peru’s efforts to reduce stunting in youth under-five years of age.

Stunting is a form of malnutrition that results from chronic undernutrition. Broadly speaking, undernutrition can present in four forms: wasting, stunting, underweight and micronutrient deficiencies. Stunting is diagnosed when a child presents with low height-for-age two standard deviations below the WHO Growth Standard deviation median. Wasting is low-weight-for-age and a sign of acute undernutrition; by definition one is wasted if he or she is more than two standard deviations below the WHO Child Growth Standard deviations weight-for-age median. Globally, the prevalence of under-five stunting and wasting are on the decline, but an unacceptable number of youths still suffer from undernutrition. In 2020, 149.2 million of the world’s under-five youth were affected by stunting and 45.4 million were affected by wasting. Among the global health and nutrition community, Peru is best known for its achievements in reducing the prevalence of under-five stunting from 28% to 13% in just eight years (2008-2016).

Stunting affects physical and mental growth. Early deficiencies in cognitive development can be catastrophic for an individual’s lifetime quality of life, educational opportunities, and economic earning potential. This has implications for the prosperity and development of nations at the population level. The economic cost of undernutrition is projected to be 2-3% of gross domestic product (GDP) on average and as high as 11% of GDP in some African and Asian countries each year. Figure 1 shows the effects of stunting on white matter tracts in the brain of a stunted infant (left) versus brain development of a healthy child (right) at two to three months of age. The density and richness of neural networks differ in the images and by the time a stunted child gets past their first thousand days they have up to 40% less brain volume compared to non-stunted children.

Figure 1: Representation of Neural Networks in a Stunted and Non-Stunted Infants.

Figure 1: Representation of Neural Networks in a Stunted and Non-Stunted Infants.
Source: Nelson, C. 2016. Brain Imaging as a Measure of Future Cognitive Outcomes: A study of children in Bangladesh exposed to multiple levels of adversity, Presentation at the Grand Challenges meeting, London, October 2016 and 2017

There is no silver bullet that fully accounts for Peru’s success in reducing under-five stunting. It can be attributed to a combination of grassroots advocacy, political commitment, and systemic changes in how nutrition services are prioritized and delivered. The details of this effective combination are too nuanced to delve into during a blog post, but the short version is: Peru’s government and leaders recognized the need to reduce stunting, it allocated money and resources to this end, and it iterated on programs and policies to reach its goal. One of my biggest learnings from the Peru case study is that health care is about trade-offs! I’ve read that health care is a triangle of tradeoffs between health, wealth, and equity. I certainly believe that to be true and it should be front-of-mind as more countries explore the means to provide a basic level of healthcare to their citizens.

Signing off,

Ashley