Stunting 101: Indonesia’s least-known health catastrophe

For a country bountiful in natural resources and food, Indonesia has a major health crisis. Can it tackle it?

Stunting 101: Indonesia’s least-known health catastrophe PHOTOS COURTESY OF SAM O’BRIEN

A young girl, aided by her mother, walks up to the pink-andblue height chart that strangers have just pasted on the wall of her home. No more than 9 months old, she does so nervously. The room is hot and overcrowded with grandparents, older children, aid workers and all manner of other people in the village on the eastern Indonesian island of Komodo. Her large eyes look up at every alien face, bewildered as to what they are all waiting to see.

Gently, her mother pushes her feet up against the chart. Everyone looks, hopeful that her tiny head will reach the proper growth range indicated by the chart. It is not even close. This girl’s future is not just one of shorter stature; there are also a host of severe developmental ramifications that will present obstacles her entire life. This little girl is stunted.

In Indonesia, especially in the provinces where stunting rates are highest, the majority of people are not even familiar with the word. This may be because, in the Indonesian language, there is literally no word that exists to define the condition. The term anak kerdil, which refers to dwarfism, is commonly used as the default term to describe the condition. Obviously, the characteristics of childhood stunting are vastly different from those of biological dwarfism, so nongovernmental organizations focusing on the problem use the English word “stunting.” Despite this, “anak kerdil” remains on much of the official Indonesian health literature distributed to areas that deal with the issue.

The problem with this distinction, though it may seem minor, demonstrates a historical lack of government attention to the problem. Additionally, while stunting rates have decreased in the most economically prosperous zones of Indonesia, the World Bank said in its 2018 report, “Aiming High: Indonesia’s Ambition to Reduce Stunting,” that in 2013, 48 percent of children under 5 years of age in the poorest 20 percent of households were stunted, an increase from 41 percent in 2007.

Due to the deleterious economic impact of stunting on communities, studies show that the condition creates a vicious cycle that exacerbates the extreme poverty that created the epidemic in the first place. Frankly put, stunting is Indonesia’s least talked about health catastrophe.

Stunting in Indonesia

For the majority of people in Indonesia who are familiar with the term, stunting usually denotes the simple idea that one is shorter than average. A stunted child is one who is below a certain height threshold. Per the World Health Organization, when “height-for-age is more than two standard deviations below the WHO Child Growth Standards median,” a child is designated as “stunted.” According to the World Bank, which uses the above definition, Indonesia had a 37 percent stunting rate for children under 5 years of age in 2018.

That rate puts the population of stunted children in the country at approximately nine million. That is a higher figure than in many of the countries usually associated with stunting, including South Sudan, Comoros and Liberia, World Bank and United Nations data show. Many countries have significantly decreased the prevalence of stunting in the past decade, while the stunting rate in Indonesia failed to improve from the 37 percent rate first measured in 2007. To say that the rate is abysmal is an understatement.

A vicious cycle

In addition to the adverse physiological effects on health, the non-physiological ramifications of stunting are the main factors serving to reinforce the cycle of underdevelopment that caused it in the first place. Frankly, a short height is the least of a stunted individual’s problems when compared with the consequences relating to developmental health, education and economics.

Concerning developmental health, stunting induces long-term comorbidities detrimental to the immune system and brain functioning at their highest capacity. A paper by the US National Institutes of Health found that “[stunting] is associated with short-term increases in infectious mortality and long-term neurodevelopmental defects” (Bourke, Berkely and Pendergast). With regard to the latter, a childhood lack of nutrition and exposure to pathogens are the main contributors to the common death of stunted children by infectious disease. For instance, it is common for children undernourished before the first 1,000 days of life to have “impaired immune organ growth and thymic atrophy” (Bourke, Berkely and Pendergast). These factors make children with stunting more susceptible to the diseases that may have caused the stunting in the first place.

Further problems ensue because a weaker immune system is consistently using the body’s energy to fight disease, doing so at the expense of crucial neurological development. John Hoddinot’s paper,
“The Economic Rationale for Investing in Stunting Reduction,” reports that stunted children tend to have worse learning skills such as working memory, attention span and visuospatial ability. These defects,
which occur in the brain of a stunted child before or during the 1,000-day threshold, create intellectual deficits that can last for an individual’s entire life. The implications of a stunted child’s weakened immune system then exacerbate difficulties relating to their educational impairments. Common infectious diseases that usually don’t keep a non-stunted child out of school often cause a victim of stunting to have lower school attendance. This explains findings that stunted individuals are “more likely to start school late, [or] to repeat a grade,” according to the journal Maternal & Child Nutrition. Eventually, detriments such as these add up to make the likelihood of failing at least one grade increase by 16 percent for a stunted child, according to a 2009 study by the Journal of Nutrition.

The dire educational consequences of stunting refuse to die off in the classroom. Instead, they follow a stunted adult into the workplace, creating a plethora of drastic economic effects at the community level. Hoddinott’s paper says that “being literate raises earnings by 10 percent, and that an additional grade of schooling, controlling for literacy, raises earnings by an addition 5 percent.” As a result of the diminished level of education that stunted adults, on average, will receive, they make less money than a non-stunted person that received higher education, even controlling for confounding factors. This reduction of wages creates a problematic type of positive feedback loop for posterity. The impoverished,
stunted adult who is unable to pay for proper nutrition and is uneducated about significant contributors to stunting, like sanitation, will replicate the same living conditions for their child. The cycle of

environmental factors, compounded with a biological susceptibility, make it rare that the first 1,000 days of an at-risk child’s life do not result in their being stunted. As Zack Petersen, director of operations for the 1000 Days Fund, an NGO working to combat stunting in 16 provinces in Indonesia, including East Nusa Tenggara, where prevalence rates average 43 percent, bluntly puts it: “Before your coffee gets cold, three kids will be born with permanent brain damage, be 10 times more prone to illness and locked into the cycle of poverty.”

Pinpointing the causes

So, what are the root causes of such a devastating cycle? The formal definition of stunting (two standard deviations below average) is accurate, but it misconstrues the causes of childhood stunting. By simplifying the condition to shorter stature, the WHO definition would have many believe that malnutrition is its sole cause. Consequently, policymakers and NGOs using this definition often focus all their energy on how much a child is eating. In doing so, they fail to combat other causative environmental factors that extend far beyond food. The reality is that childhood stunting is a result of several interacting factors that come together in different sectors of a child’s life. In both the prenatal and postnatal periods, poor maternal child-rearing habits constitute a significant factor contributing to stunting. For example, according to the World Bank, iron deficiency anemia, which correlates to low birth weight, affects 37 percent of pregnant mothers in Indonesia. Although most posyandu, or integrated health centers, offer free supplements such as iron in rural Indonesian areas, mothers often
do not take them. The low birth weight driven by anemia can result in congenital health defects at birth that make it more difficult for a child to grow no matter how they are nourished. Furthermore, chances for stunting increase if infants are not exclusively breastfed for at least six months. The World Bank says this is happening for only half of all children in Indonesia, as “aggressive marketing of formula to mothers” has put pressure on parents to switch from breast milk as early as possible. Tragically, this is the opposite of what children truly need.

At the community level, lax standards for sanitation and hygiene may be the most crucial factor perpetuating the stunting epidemic. “Stunting is 70 percent sanitation, clean water and hygiene … 30 percent nutrition,” says Petersen. There is a great deal of evidence supporting this line of thinking. In Indonesia’s affluent urban areas, where public sanitation facilities have improved, stunting rates have decreased. Further evidencing the correlation, the World Bank reports that children who live with less open feces and improved sanitation are less likely to be stunted. So it makes sense that stunting rates have increased in Indonesia’s most deprived rural areas, where, in 2015, the United Nations Children’s Fund reported that 29 percent of people still defecate outside. This lack of sanitation is especially prevalent in the island areas of East Nusa Tenggara Province, where the ocean offers a natural substitute for a toilet, and stunting rates in the region are far above average.

Possible scientific evidence for this theory was proposed in the 2014 paper “Beyond Malnutrition: The Role of Sanitation in Stunted Growth,” which postulates “environmental enteropathy diverts energy from growth toward an ongoing fight against subclinical infection.” Child malnutrition is a factor in stunting – an important one – but the many environmental factors are just as, if not more, important because they are both unknown to the public and they have the most potential to be easily improved by governing bodies.

Lack of improvement

In Indonesia, neglect of the posyandu system, the series of local health facilities that specialize in monitoring child and maternal health, is at the root of the stunting crisis. In regions where prevalence is highest, a “perfect storm” of underdeveloped posyandu and untrained health workers fail to educate villagers about what stunting is and how to prevent it. For there to be positive change “the posyandu, established in 1986, should spearhead prevention of stunting in the later stages of the first 1,000 days,” says Soekirman, a former director general at the Indonesian Ministry of National Development Planning.

Although the posyandu system seemed promising when established by President Soeharto in 1986, major events such as the 2001 “Big Bang Decentralization” (World Bank) have shifted jurisdiction over the health centers to the domain of local government. The “Big Bang Decentralization,” although positive in many ways, resulted in significant losses in the efficiency of the posyandu system. Mainly, this was a consequence of economics, as the national government no longer mandated the equitable division of funds for health and sanitation in local areas.

Instead, the decentralized government distributes these funds to the most populated cities in a particular region, whose governing bodies are given the discretion to allocate the funds to surrounding towns. The money never trickles down. This has created problems for elected village leaders trying to spearhead the provision of essential utilities in their communities. With reduced funds, these leaders have to make tough decisions, often sacrificing health programs in favor of other critical initiatives. In Indonesia’s rural communities this results in a posyandu system that is more disorganized, outdated and underdeveloped than ever.

Turning things around

Any solution to the childhood stunting crisis must involve greater recognition and action by governing bodies. In recent years, the administration of President Joko Widodo has set forth several strategies to address these issues. Recently, the Ministry of National Development Planning set the lofty goal of reducing stunting to 10 percent prevalence by 2030. In August 2017, the president partnered with the World Bank on the National Strategy to Accelerate Stunting Prevention, which details the complexity of the stunting issue and what can be done to stop it. In the World Bank report, the president pledged to “attack stunting together with local governments, teachers, health workers and parents.

While recognizing the problem is a start, implementing actual policies is necessary to make sure Joko’s promises are not just empty words. In large part, the stunting epidemic is a result of education, infrastructure and health failures at the local government level. In general, improvements in Indonesia’s most impoverished communities have been thwarted by a lack of federal funding and economic support from local tax revenue. An example of this are the villages located within Komodo National Park, which suffer because money from the land goes to the largest city in this eastern region, Labuan Bajo. Because of this, Labuan Bajo has been able to improve public services, generating more economic activity, at the expense of smaller islands to which more funds should
be allocated.

To ameliorate the situation, the national government needs to play a more significant role in all these sectors. A better education system, for instance, would make villagers and local health workers more knowledgeable about general health practices that should be taken up in the village. Also, programs to train health workers in the procedures for measuring child growth correctly would be extremely beneficial in enabling them to inform parents about their child’s health. And improved training would allow them to advocate for stunting prevention practices by pregnant women. Lastly, a more centralized effort to make sure all communities, especially those known to be affected by stunting, are brought up to the minimum service standards for sanitation and hygiene by the Ministry of Health would significantly improve circumstances.

In addition, NGOs play a vital role in fighting stunting. These organizations can raise awareness about stunting among parents and health care workers in communities where the government fails to do so. For example, Petersen’s organization, the 1000 Days Fund, achieves this through placing height charts in houses of parents with children under the 1,000-day threshold. A Gates Foundation-funded study shows that charts such as these have succeeded in reducing stunting by as much as 22 percent.

These charts go far beyond just measuring height. They also feature necessary information about health practices to improve overall health in communities. According to Petersen, “The
charts are meant to be the centerpiece in a package of village-level interventions that involve everyone from religious leaders and village health volunteers to elementary school teachers.” This coordination is paramount to the long-term success of such NGO operations, as real anti-stunting habits need to become intrinsically motivated within villages. Thankfully, organizations such as the 1000 Days Fund incentivize this coordination by holding health worker training sessions about stunting and
subsequently paying health workers to distribute height charts. If the government and NGOs can collaborate, with the former providing a share of the incentive while the latter continue to provide free training programs, there is tremendous potential for progress.

The payoff

If the key players take appropriate measures, reversing the stunting epidemic does more than provide a health service that is long overdue. These initiatives are the key to unlocking the vast future economic potential of Indonesia. With government investments in infrastructure, sanitation and education, more business and economic opportunities will come to areas where they are most needed.

A non-stunted worker can accomplish higher-skilled, more reliable and more productive labor. In turn, this more capable work force would fuel Indonesia’s rapidly growing economy. This growth would boost
household earnings along with the accounts of local governing bodies. The economic rationale for investing in reducing stunting calculates that for every $1 of investment by the government, there is a $48 return on investment. This monetary return refutes the common misconception that stunting is solely a humanitarian issue. Yes, the young girl who is four inches shorter than she should be, and whose lungs rattle when you pick her up, is the direct beneficiary of the reforms that are proposed to stop stunting. However, by helping this girl, one helps her children and her community, and ultimately her country.

Sam O’Brien is a contributor to Strategic Review.

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