Dr. Zulfiqar Bhutta: 'Healthy children are your scientists of tomorrow'

Dr. Zulfiqar Bhutta is keenly aware of the dilemma surrounding stunting.

Stunting is one of the biggest global challenges we face today. The impaired growth and development children experience mainly from poor nutrition and repeated infections – also known as linear growth failure – has dire and lasting consequences. Stunted children have an increased risk of infections, non-communicable diseases, and early death. They also face greater risks of neurocognitive damage that can hinder them both in school and, later, in their working and personal lives. Moreover, for nations, a generation of stunted children can mean major losses in economic productivity and increased health burdens that can be felt for decades and across generations.

On the other hand, tackling stunting in a sustained fashion can take time and that means it's not a very "politician-friendly indicator," said Dr. Bhutta, the Robert Harding Inaugural Chair in Global Child Health and co-director of the Centre for Global Child Health at the Hospital for Sick Children in Toronto. "One of the problems is that very few politicians or governments have the staying power to invest (in stunting) for the next government. They all want quick fixes with results within four or five years and they want change to be visible, and changes in stunting rates may not be very obvious."

In this second part of an interview ahead of the Micronutrient Forum's global conference starting Oct. 16, Exemplars News spoke with Dr. Bhutta, who is also the founding director of the Centre of Excellence in Women and Child Health and the Institute for Global Health and Development at Aga Khan University and an Exemplars in Global Health research partner, about why stunting remains such a critical issue.

What progress has been made in terms of global stunting reduction and what challenges remain in achieving these targets?

Dr. Bhutta: In terms of global progress, the numbers of stunted children are going down very slowly. We're now at about 148 million stunted children globally, with huge global challenges, often of a complex nature. We have just begun to emerge from an unprecedented pandemic where the world stood still. Economic growth stalled in countries and with the global effects of conflict in Europe, poverty rates have climbed. There has been displacement from conflict and climate change. Many of the countries where stunting is prevalent have virtually decimated economies. I think we're also beginning to realize that to look at maternal or child nutrition, stunting or wasting through a very narrow lens of health and nutrition is myopic and these conditions are very much dependent upon what's happening on the outside.

For example, I'm currently in Kenya and I've been asking people about the cost of living. Even though they're relatively protected here – they haven't had a massive pandemic and they haven't been impacted by climate change in the same way as their northern neighbors – people are hurting. People are poorer than they were before and that impacts to a large extent how much they can spend on good quality food, etc. The world is facing an unprecedented crisis of food security. And these impacts are much worse in my country of birth and work, Pakistan, where a series of crises have pushed over half the population into abject poverty and food insecurity.

Improving nutrition for vulnerable populations of young infants, children, and mothers is one of the most important interventions you can make to reduce long-term consequences and promote inter-generational health and economic well- being. But, as I said in a recent comment in The Lancet, one big challenge is that there is not a single government out there, not a single political leader in the G20, who is talking about public health nutrition or childhood malnutrition. I was so disappointed by the BRICS Summit in August – here you had a meeting in South Africa of the leaders of the lower- and middle-income countries (LMICs) and nobody said anything about undernutrition, even though just a few weeks earlier the State of Food Security and Nutrition in the World 2023 report was released and there couldn't have been a greater indictment of how the world needs to do better for its women and children.

This is also happening at a time when there is overall no global food shortage, even though this varies across countries and regions. If you look at global food production, aggregating higher-income and middle-income countries, there are food surpluses. It's just not reaching the people at the bottom of the pile. We need better distribution systems through mechanisms based on global solidarity and a common mission – and I don’t mean charity. We need better systems of equitable economic support and we need better systems of debt relief for some of the poorest countries of the world caught in debt traps and structural adjustments.

So how can we sustain interest in nutrition and stunting when there are so many competing issues?

Dr. Bhutta: Changing growth patterns in populations takes decades, but one of the problems is that very few politicians or governments have the staying power or interest to invest for future generations. That's one of the reasons why stunting is not a very politician-friendly indicator. But it's a scientifically valid indicator – and it's an indicator that we've shown is not cast in stone and can change. And our work and experience very strongly refute the move to change goal posts for measuring and monitoring stunting and move to other indicators.

To counter some of this, let's say, fatigue, with the term 'stunting', we could use a better explanation of what we're talking about. I hope we are moving towards a more holistic definition of childhood undernutrition or growth failure that takes into account the fact that growth is complex and relates to both nutrition and non-nutritional factors.

Are there any recent success stories or best practices from countries that have effectively reduced stunting rates you would like to highlight? What strategies have they employed?

Dr. Bhutta: Absolutely – a number of countries have been able to reduce stunting with average rates of reduction of between 3% to 5% per year, which is a massive success. And these are not rich countries. Ethiopia and Nepal are two examples – and these are some of the poorest countries in the world that have achieved success despite poverty, crippling conflict, and environmental challenges.

What we are finding across these countries are common lessons. One of those is that you have to address the social determinants of health, including poverty, women's health, education, family planning, food security, and dietary diversity. And, also importantly, conduct nutrition interventions during sensitive time periods where their impact can be maximized, such as during antenatal care, early childhood, and adolescence.

One of the fascinating things is that despite tremendous differences in context in many of these countries, one of the uniting principles was that they invested in broad holistic nutrition improvement programs and, at times, in health improvement programs. Some of those programs were not focused on stunting reduction per se, but on reaching the poorest of the poor and reaching people with services in the most deprived geographies.

For example, in Peru, the government had a cash transfer program to support the poor and their biggest challenge was people living in the highlands. They set up a program to create employment opportunities that also encouraged people living at very high altitudes in very food insecure environments to come down to the cities to increase their economic stability and ability to purchase food. That paid dividends within a generation. Those who used to think that Peruvian highland dwellers were all genetically short couldn't have been more wrong.

How has the COVID-19 pandemic affected efforts to combat stunting globally and what lessons have been learned from this experience?

Dr. Bhutta: There's no doubt there was an impact early on, particularly when there were stringent measures like lockdowns. But in all fairness and looking at the data now, those extreme stringent measures only lasted a few months. So much of the impact of COVID on stunting was through the pathways that I've just mentioned – the poverty cycle people got into because they became unemployed and the global economy shrank. And almost no LMICs had poverty alleviation programs that targeted the underemployed or unemployed, and the benefits of remote working largely passed to those with higher education, skills, and opportunities.

Secondly, many key programs that supported things like school nutrition programs closed. In Africa and parts of Asia, people did not realize how critically important these school nutrition programs were for young children. And even in North America, there was an outcry when school nutrition programs closed because people realized how much food insecurity there was in their own backyards.

This was all compounded very rapidly, particularly over the past 18 months with the impact of war in Ukraine on things like food systems, supply chains, and the availability of staples like wheat. The Ukraine crisis has also had a major impact on development assistance. So much money has gone into this conflict that countries which have typically been very supportive of international development, such as the U.S. and U.K., have also cut their development assistance budgets. The impact of COVID and conflict was also multiplicative on support systems, and the only way countries could survive was to take on more debt – and now they're paying the price for it, teetering on the brink of defaults.

Could you tell us a bit more about the role of maternal nutrition in preventing stunting and how can interventions before and during pregnancy and with adolescent girls can contribute to reducing stunting rates?

Dr. Bhutta: One of the most fascinating pieces of research I conducted was an analysis of the drivers of nutrition in Pakistan and Afghanistan some years ago. We were looking at risk factors or predictive factors for stunting on the basis of large surveys that included predictable factors like poverty, food insecurity, and health system performance. But two things jumped out. Firstly, that low maternal BMI (body mass index), which is wasting in mothers, was an important driver of stunting. And secondly, that maternal height by itself was a separate predictor of stunting. Both were independent. For a long time, I could not figure this out and I thought maybe there would be some degree of confounding. However, the relationship was robust and independent – and the reason was that maternal wasting was a reflection of what happened to maternal nutrition during the pregnancy period. And the mother's height was reflective of what happened much earlier to the mother, not only to in her own childhood, but perhaps also the height of the grandmother.

There are intergenerational impacts of linear growth retardation. A mother's nutrition impacts growth in the first six months particularly, and then throughout infancy in several ways. We forget that at the time of birth, the baby is already nine months old. The whole fetal growth period really drives and determines whether the baby is healthy across the life course. Therefore, it stands to reason that if the mother has health issues, not just nutrition issues, they will impact fetal growth. The second thing is that many of these things impact not only linear growth, but also brain development and human capital, therefore the invisible part of the consequences of under nutrition.

Studies have shown that poverty and early exposure to adverse factors have lifelong consequences. I've just published a paper in Nature Medicine that relates adverse early childhood exposures to long-term outcomes and health. We know a mother's nutrition and health impacts the baby throughout pregnancy and early childhood. When the mother is undernourished or unhealthy or has mental health issues, they're also often unable to look after their baby properly in the first few months of life and this has been shown to impact nutrition outcomes.

Are there innovative technologies or approaches that show promise in addressing stunting on a large scale?

Dr. Bhutta: We know there are many innovative strategies to reduce poverty, particularly female poverty. There are also innovative strategies that can reach marginalized populations through targeted interventions, such as conditional cash transfers and large-scale fortification programs. There are also strategies to reduce the nutritional penalty that women pay, in particular if they have frequent pregnancies, through improved family planning programs. All of these have made major contributions to improving maternal health and nutrition and, in turn, the child’s nutrition.

We also know that in populations where there is poor access to services having community health workers reach out to the poorest of the poor and the most marginalized populations yields benefits. We've seen these examples well demonstrated in Ethiopia, Nepal, and Pakistan, among others.

And I want to mention my favorite – investments in water, sanitation, and hygiene (WASH). Although the randomized control trials may not tell you that there are benefits of WASH, real life is very different from randomized controlled trials. You go to these countries (where WASH programs have been implemented) and see the value of these investments in reducing open defecation, providing clean water, and sanitation services over time. Our Exemplars studies consistently show the contribution these investments make in improving linear growth in country after country.

How could we ensure there is better buy-in and support from governments to reduce stunting?

Dr. Bhutta: We need to present stunting programs as an investment rather than a cost. That's why I think we should be advocating for a lot of these stunting-related programs not to ministers of health but to ministers of finance. The reasoning for improving nutrition outcomes is, compellingly, the impact over generations and improving the health and wealth of nations. You can advocate for human development potential. You can emphasize to policymakers by saying a healthy population cohort of children are also your scientists of tomorrow. India has gone to the moon today not just because India invested in science and technology, but also by improving the health, nutrition, and educational status of its population.

And secondly, this investment is best made with an eye on intergenerational benefits so you don't shortchange programs and stop them in a mere four or five years because you don't see any evidence of benefit straight away. Programs that improve the environment, reduce poverty, and improve nutrition yield benefits over decades and are an investment to improve the health and wealth of nations. That's the fundamental message.

This interview was edited for length and clarity.