By Zack Petersen
Erna didn’t hesitate when asked to bring her son Imron forward to measure him against the colorful chart stuck to the wall. But when Imron, barefoot and wide-eyed, leaned his head back and touched the line that indicated the average height for a nine-month-old boy, she blinked.
“How old is Imron?” the field officer asked the young mother, as she glanced back-and-forth from the crumpled World Health Organization Z-scores in her hand to the height chart.
“He’s 19-months-old,” said Erna.
Imron, was the first child measured on Messah, an island on the fringes of Komodo National Park, some 1,500km east of Indonesia’s sprawling capital, Jakarta. Imron was three standard deviations below the median height for his age, the average 19-month-old boy should be 83 centimeters tall, Imron was 74 centimeters tall. This might not mean anything to people who have never heard of a standard deviation, and even less if they have never heard of stunting.
But for those who know of stunting and the World Health Organization’s Child Growth Standards—then four standard deviations should leave a lump in your throat.
What can be done to reverse stunting? Almost nothing. Some 80 percent of brain growth happens during the first 1,000 days of a child’s life. When that window closes, it closes for good.
Stunting is a massive problem in Indonesia, both in terms of scale and impact. Every day, 14,000 children are born across the world’s largest archipelago. Of those 14,000 children, more than 5,300 are likely to be stunted. In fact, every third child born in Indonesia—more than 37 percent—has the potential to be stunted. Those same kids are 10 times more prone to illness, are more likely to drop out of school and will earn 20 percent less as adults than their non-stunted peers.
A failure to act during the first 1,000 days of a child’s life—from conception to two years old—has irreversible effects, both on the individual and the economy. Mounting evidence, suggests that the stunting penalty— the overall cost of childhood stunting among today’s workforce for Indonesia—is 10.5 percent of GDP.
What can be done to reverse stunting? Almost nothing. Some 80 percent of brain growth happens during the first 1,000 days of a child’s life. When that window closes, it closes for good.
Against this backdrop, stunting will likely take center-stage at this week’s IMF-World Bank Meetings in Bali from October 12-14. The world’s policymakers, activists and academics will gather on the ‘Island of the Gods’ to discuss water, sanitation, nutrition and women’s empowerment—all four potent defenses in the war on stunting.
Heated discussions will center around the World Bank’s Human Capital Index (HCI), of which stunting is one of four indicators. The HCI, the Bank explains, aims to create political space for national leaders to prioritize transformational human capital investments in their countries. The world is waiting to see where Indonesia ranks.
Development experts and bureaucrats from local CSOs and international development organizations will stand behind podium after podium, at meetings and conferences toting log-frames and strategic annual plans, but will likely fall short when asked whether or not their efforts have had any real village-level impact. More often than not, the stunting conversation in Indonesia stalls around two key words: “complexity” and “access.”
In a country covering the distance from London to Tehran, the question of access will always find its way into a conversation. Access to water. Access to toilets. Access to iron and folic acid. Access to education and information.
The latest push from the government has been to put the posyandu back in the spotlight. Decades ago, the posyandu, or the Pos Pelayanan Terpadu (Integrated Health Service Posts), served as the lifeblood of the village. But of the more than 300,000 posyandus in Indonesia, no one knows how many are still operational, or, more importantly, which ministry should oversee the day-to-day operations of the facilities.
If the war on stunting is won and lost in the trenches, Indonesia’s midwives serve as the frontline of Indonesia’s healthcare system, bolstering the posyandu activities and, in many cases, representing the only contact poor Indonesians will have with that system throughout their lives.
Stunting, however is not limited to the rural, far-flung islands of Indonesia. Jakarta, the nation’s buzzing capital, is home to a 27 percent stunting rate. Just as in Komodo, a lack of toilets and access to clean water plays a significant role. The latest data shows more than 70 million Indonesians do not have a toilet. Many of Jakarta’s citizens defecate directly into dozens of rivers that snake past high-rise apartments and luxury malls.
Recognizing the impact stunting has had on Indonesia, President Joko Widodo addressed the issue in his most recent state of the nation address, delivered on August 16, promising that his administration would “work to ensure that every Indonesian child is born healthy and grows with adequate nutrition and is free from stunting.”
More importantly, with the recent launch of “Aiming High: Indonesia’s Ambition to Reduce Stunting”, the World Bank’s remarkable roadmap to successfully accelerate stunting prevention in Indonesia, the president has publicly pledged to ensure that 2 million children “born between now and 2021 will be healthy and productive individuals with a fair opportunity to succeed in life,” and called on his cabinet to lead coordinated effort across ministries to devise integrated action plans to tackle stunting, and push for concrete ways to innovate and incentivize community-run activities.
The height charts distributed by the field officer and her colleagues in Komodo, where the stunting rate is a staggering 52 percent, were inspired by a recent Gates-funded study in Zambia. The study found that providing parents with full-sized height charts, which included information about nutrition and were placed on the walls inside homes, reduced stunting rates among already chronically malnourished children by 22%.
In each village, the team deliberated the slings and arrows of sanitation, nutrition, exclusive breastfeeding and stunting. They begged bidan (midwives) for answers and bartered with mothers about the ages of their children. A clear majority were stunted. No one had toilets. Very few children were exclusively breastfed for the first six months of their life. Access to clean water was limited and some mothers had to walk for six hours to get fresh water. Goats peeked their heads into houses and rested their chins on windowsills while the team hung height charts and chatted with mothers. Diarrhea is so common it’s not even considered an illness.
The team left Komodo with more questions than answers.
According to UNICEF, Indonesia could slash stunting by 25–50% if it would invest an additional USD100 per child, with a 90% target population penetration rate. It’s also estimated that every US dollar spent on reducing stunting in Indonesia will generate US$48 in economic return.
But that would mean real work and accountability at the village level. With 75,000 villages, Indonesia will need to hold policymakers and NGOs alike accountable for their ability to unleash village-level interventions that speak directly to mothers and primary caregivers, rather than feckless strategies laced in jargon and devoid of intention to get their hands dirty at the village level.
So for Indonesia, the obstacle is the way.
The IMF-World Bank Annual Meetings will provide the world’s fourth most populous nation with the perfect opportunity to show the world just how much they care about boosting equality and ensuring that the next generation is given the opportunity to grow, thrive and prosper in the global economy.
But for Erna and Imron it’s now or never. The hope is that the bold plans unveiled on Bali reach the villages of mothers and children who need it most before it is too late and another generation of Indonesian children are left behind.
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The writer works for the 1000 Days Fund, a philanthropic endeavor based in Singapore.
