Students and global health experts share their experiences working with communities.

Category: Ashley

Nutrition Lessons from Peru

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,


Working from Home with the World Bank

My work from home setup: complete with a makeshift standing desk, breakfast, and UNC memorabilia.

My work from home setup: complete with a makeshift standing desk, breakfast, and UNC memorabilia.

As I inch towards the end of my master’s program and the real-world beckons, it’s been challenging to articulate my immediate and long-term career ambition to friends and family. I am still working on my elevator pitch, and I can’t fault those for whom the words “development,” “social determinants of health,” and “malnutrition interventions” makes them nod in vague understanding. To begin with, the world of healthcare is esoteric, and until around March 2020, few laypersons had given any thought to what public health as a discipline was all about. When I am doing a good job of describing my career interests, I say something to the effect of, I want to focus on the challenges associated with reducing global health disparities and addressing upstream determinants of poor health outcomes. To the greatest extent possible, I believe healthcare systems should promote health, rather than treat disease. That is why I’m passionate about nutrition and the potential it has to spur improvements in the quality of life for individuals, families, communities, and nations. As evidence, take the World Bank’s estimate on economic loss due to undernutrition. The cost of undernutrition (defined as stunting, wasting, underweight, and micronutrient deficiencies) 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. Likewise, the costs of overnutrition, commonly manifest as overweight and obesity, are linked to expensive health expenditures associated with chronic non-communicable diseases such as type II diabetes and hypertension. Investment in nutrition is too important for governments and nations to ignore.

Given my passion for global nutrition and global health, this spring and summer I am partnering with the World Bank as a Short-Term Nutrition Consultant. The experience will serve as my Advanced Nutrition Experience for the MPH with registered dietitian training program. I will contribute to the report Positioning Nutrition within Universal Health Coverage: Optimizing Health Financing Levers. The project seeks to provide practical knowledge for policymakers about how health financing can be used to improve nutrition service coverage and quality.  I am responsible for conducting desk reviews for several low and middle-income countries (LMICs). The project’s final deliverables include a policy note and country case studies that will be presented at the 2021 Nutrition for Growth summit in Tokyo.

I’m excited by the opportunity to work with such an established and well-connected organization. During this experience, I look forward to working with highly intelligent, highly motivated people who are trying to solve some of the world’s most pressing issues around hunger, malnutrition, and overnutrition. I hope to walk away with a bird’s eye view of the nutrition situation in LMICs, and a deeper understanding of the day-to-day tasks of a nutrition specialist. Finally, I’m grateful to be working with a team of experts on the project! So much of the past year and a half has been spent in academic isolation. During my experience I will still work remotely, but I’ll get the opportunity to participate in weekly conference calls and collaborate on document drafts with the team. Hopefully by the end of the summer I will have my future plans elevator pitch perfected!

Until next time,