Poor nutrition in first two years has permanent effect on growth and development, and could spell disaster for country
Afghanistan is raising a stunted generation, whose hobbled development could spell disaster for the country's feeble economy and undermine the impact of billions of dollars in aid poured into health, education and other areas.
More than half of Afghan girls and boys suffer damage to their minds and bodies that cannot be undone because they are poorly fed in the crucial first two years of life, doctors and experts say. The revelation raises serious questions about the legacy of more than 10 years of western involvement in Afghanistan.
"After the age of two years, stunting is largely irreversible, and has an impact on growth and development and cognitive function," says Carrie Morrison from the World Food Programme. "Over the longer term, it can have a very damaging effect on the national economy. Young people are not able to attain what they should be able to attain. Women who marry young and are stunted themselves give birth to a small infant and the cycle goes on."
The problem of children who are not getting enough nutrients from their food is known as chronic malnutrition. It afflicts poorer countries worldwide, but in Afghanistan it is particularly widespread and persistent.
A decade after the fall of the Taliban, 55% of the country's children are stunted because of inadequate food, Afghan government and UN data shows.
The statistic is damning for western powers which have poured billions into Afghanistan to fund development and reconstruction. The US alone has spent $90bn (£54bn). Such funding aimed to transform Afghanistan from an impoverished, unstable country of largely subsistence farmers into a more modern nation, but return on that spending has been low.
With troops soon to head home, the returns have been limited. Violence is spreading and Afghanistan remains one of the world's poorest countries, with low life expectancy and poor healthcare for mothers and young children.
The malnutrition problem is caused by the basic poverty of those who can't afford healthy food, as well as poor hygiene and healthcare, child marriage, and a web of other issues.
"We have whole families where food insecurity means they are all malnourished, but we [also] even have rich families that have one child who is sick," says Alam Mohammad, a 25-year-old doctor who swapped the chance of an easy city practice to work in Feroz Nakhchair, on the gruelling frontline of a fight for the country's future.
Half an hour's drive down a dirt track from the nearest country road, in a valley on the fringes of Taliban territory, he sees dozens of cases a day like Mojabeen, whose leopard-print dress beneath her burqa seems incongruous with her life of constant hardship; at 19, she has three children and the family live in a one-room house on a flood plain that is periodically inundated.
Her husband earns $2 or $3 a day, if he can find work, which is not enough to feed the small family. "My second child is living with my mother, as we can't provide for him," says Mojabeen, as she waits for her baby to be weighed and examined.
Her children were at a disadvantage even before they were born because Mojabeen was so starved of nutrients that she could not pass on what they needed during pregnancy. In a district of around 13,000 people, the problem is so widespread that a programme set up for around 100 pregnant and breastfeeding mothers is already serving more than four times that number.
Nevertheless, it can be hard for charities and the government to focus attention or funds on chronic malnutrition when the country is battling a more dramatic type of hunger, which is also easier to address: acute malnutrition.
In clinics nationwide tens of thousands of babies and toddlers have experienced such severe shortages of calories that they have the protruding bones and distended stomachs familiar from photographs of famine victims. Acute malnutrition affects more than one in four children in some areas, but it can usually be resolved relatively quickly with a steady supply of high energy Plumpy'nut feeding paste.
In some ways, chronic malnutrition is harder to tackle as the children suffering from it often don't show their desperate need for help.
"You might see a child who appears underweight, or short for their age, but it doesn't really tell you much unless you line them up against a well-nourished child. But it prevents them growing up to lead a more productive life," says Morrison.
But appearances are disastrously deceptive. "It prevents them growing up for a productive life," she adds.
A lack of iron, which affects three-quarters of Afghan children, reduces activity and productivity. In young children, it disrupts brain development with effects including "stunting, sickliness, poor school attendance, and lower levels of concentration and memory". A lack of iodine "is the world's leading cause of preventable mental impairment", and a lack of vitamin A hobbles the immune system, pushing up death rates among children under five.
So severe is the damage that tackling it by lacing basic foods such as salt and flour with micronutrients has been rated one of the most economical ways to do good. "In the worst-affected countries, the benefits of supplementation with vitamin A and zinc can be up to 100 times higher than the costs," according to a research paper on the impact of giving children "micronutrients" – generally known in the west as "vitamins and minerals".
Recently, the government launched a five-year programme to fortify flour used to make ubiquitous nan flat bread – often the only daily food for poor families – oil and other foodstuffs. Gradual progress with women's education, healthcare and hygiene education is expected to bring slow but important progress.
A recent World Bank study found a direct link between sanitation and height: a five-year-old child in a community where everyone uses a toilet is on average more than 2cm taller than a child from one where people defecate in the open.
But poverty is also a pressing problem, in a country where a third of all citizens do not always know where their next meal will come from. A recent UN study found even a minimally healthy diet was beyond the reach of the majority of Afghans; in some provinces, only one in five could afford balanced meals.
And while the government and aid workers try to address problems that can take years to solve, healthworkers are often hobbled by a focus on more apparently pressing problems.
"We do worry about chronic malnutrition, but all we can give them is advice," says Nehmatullah Majidzafa, a nutrition nurse at an Oxfam-supported project in the shadow of the ruined ancient city of Balkh, where most funds support feeding the children in most obvious need.
That includes hands-on demonstrations, with nurses chopping onions into a basic pressure cooker before adding lentils, rice and vegetables, and warnings to spend spare money on protein rather than the cookies and cakes that many lavish on their children.
The information does help, because "parents don't know much about health here", says Mohammad, the doctor in Feroz Nakhchair, but still it troubles him to see those who arrive beyond the reach of his help. "If a child comes in after too long with chronic malnutrition, he cannot fully recover. We can only teach the parents so they take more care it doesn't happen with the other kids."
Hunger in Afghanistan
Extreme poverty and a harsh climate mean many Afghans go hungry. One-third of the population do not get enough food to live healthy, active lives, and another third hover around the borderline of "food insecurity", or not knowing where their next meal will come from. But the food shortages are particularly damaging to young children, who need to develop fast.
International studies show that children who are properly fed can earn between a third and a half more as adults than those who did not get a proper diet, the World Food Programme's Morrison says.
And overall malnutrition shaves 2%-3% off Afghanistan's national income each year, the World Bank says. That's around half a billion dollars lost to an already very poor country.
guardian.co.uk © Guardian News and Media 2014