JAKARTA: “I had four children, but two of them died,” Karimah said flatly.
“The second child was born at home. When he was born, he wasn’t crying, wasn’t doing anything. The third child was born in the hospital. My delivery date was still a long way away, but I felt a stomach ache. They told me I had amniotic fluid poisoning. He was in the NICU (Neonatal Intensive Care Unit) for four days, and then he was gone.”
Karimah, a vegetable seller who goes by only one name, looked up at the ceiling of the clinic in Sukadami village, in West Java, dangling her youngest child on her knee.
“Two months after Gafar died, I became pregnant again with Najwa.”
Karimah stroked her daughter’s hair. Najwa Syaqila was dressed in a bright pink pinafore, and like most two-year-olds, she was restless, squirming in her mother’s arms and wriggling to get free.
It is her that Karimah worries about now. Karimah struggled with all her pregnancies, and with Najwa, this struggle centered around food.
“For the first two months of my pregnancy, I couldn’t eat rice, only fruit and biscuits.”
After she was born, Karimah suspected something was wrong. “I was suspicious from the start. When I compared her to her friends, the other children in the village, I could see that my child was quite short. So when I was told that she was stunted, I wasn’t too surprised.”
Karimah’s neighbours in Sukadami scoffed at first. “If the mother is short, what - the child has to be tall?”
Just 50km away from downtown Jakarta, Indonesia’s capital, the village of Sukadami has the highest level of stunting in the greater metropolitan area.
A term used to describe children who are short for their age due to poor nutrition, it can have significant negative effects on more than just their physical development.
These effects are considerable. There is an increased likelihood of stunted children dying before they reach their first birthday, and those like Najwa who survive into early childhood have weakened immune systems.
This means that they are more susceptible to diseases like diarrhea, and later in life, degenerative diseases like diabetes, hypertension, and coronary heart disease.
There are children like Najwa all over Indonesia. At the beginning of 2020, there were an estimated 7 million children under five years old who were stunted.
“Indonesia is considered to have the fifth-highest number of stunted children in the world,” said UNICEF Indonesia chief of nutrition Jee Hyun Rah.
According to a 2019 national health survey, 27.7 per cent, or more than one in four children, are classified as stunted. This rate rises sharply in remote areas, where health services may be less developed and where a higher proportion of the population may rely on subsistence farming.
In East Nusa Tenggara for example, 27 per cent of children live below the official poverty line of 9,793 rupiah, or about US$0.70 a day. There, the stunting rate was 43 per cent, or almost half of all children in the province, according to Dr Melania Gondomartojo, head of nutrition at the World Food Programme in Indonesia.
Realising its negative impact on the country’s economic growth, the Indonesian government has set a goal to reduce the stunting rate to 14 per cent by 2024.
In 2017, the National Strategy to Accelerate Stunting Prevention was formulated to bring together 22 different ministries, regional government, the private sector, and civil society groups to tackle stunting.
The multi-pronged approach has seen positive development, bringing down the national stunting rate by almost 10 per cent from 36.8 per cent about a decade ago, in 2008. But challenges remain, especially at a time of global pandemic.
MULTIFACETED AND COMPLEX CAUSES
Stunting is undoubtedly a concern because of the immediate repercussions that poor nutrition has on children’s health, but also because of its negative effect on children’s cognitive development.
Children like Najwa face an uphill battle in academic achievement and have a higher chance of dropping out of school before their education is complete.
This leads to difficulties in the job market and much lower earning potential, and a higher probability that they will live in conditions of poverty their entire lives.
A lack of nutrition is not the only cause of stunting, however. The causes of stunting are multifaceted and complex, comprising nutrition, a lack of knowledge, access to health services, maternal health, environmental factors and more.
When it comes to nutrition, it is not simply a matter of quantity - how much children are eating - but of quality as well.
Dr Sri Eni Meniarti, chief medical officer of Bekasi, a city located on the eastern border of Jakarta, has seen stunting affect families at a range of different income levels in Sukadami and the other areas she oversees.
“There is an attitude that what’s important is just that children eat,” she said. “But the nutritional composition of food isn’t looked into.”
This lack of knowledge around what constitutes good nutrition means that being told that their child is stunted may come as a surprise for some.
This was the case for Fahmi Aryati, a mother of three. Her husband lives hundreds of kilometres away, in Lampung, South Sumatra, where he got a job as a carpenter. Back in Bekasi, Aryati makes a living selling vegetables while balancing childcare duties.
Last year at her community health centre, she was told that her youngest child, two-year-old Intan Ayu, was stunted. “I was sad, because I thought she was getting enough food. But it meant that she wasn’t. I had so many questions. How could she be stunted? How could this happen?”
ENVIRONMENT PLAYS A PART TOO
Environmental factors also affect whether children are stunted, both in terms of food security and as it relates to hygiene and sanitation. In Bekasi, where Aryati lives, frequent droughts mean that those who rely on farming face loss of income, and cannot afford to feed their children adequately or consistently.
In other areas, climate change-induced flooding and rising sea levels threaten sanitation systems. In some areas, many families do not have their own toilets, using shared facilities or being forced to defecate in canals or other open spaces.
According to a joint monitoring programme report published by the World Health Organization and UNICEF, over 41 million people living in densely-packed urban areas in Indonesia do not have a handwashing facility in their home.
All of this means that those with sanitation challenges, urban and rural alike, are more prone to diseases like dysentery, cholera, and diarrhea. For stunted children, who have weakened immune systems, this can be severe - and even fatal.
Diarrhea is the leading cause of child mortality in the country, and for those who survive it, it has a severe impact on the amount of nutrients the body can absorb.
It is the prospect of falling ill that Aryati fears for Intan. “Nowadays there are so many viruses. So many illnesses. I fear that she might catch one. That’s what I fear.”
Aryati is lucky, in at least one respect: although the risks of illness are serious, they are mitigated by her easy access to Bekasi’s health services.
“For the most vulnerable population groups living in rural or remote areas,” said UNICEF Indonesia’s Rah, “they have difficulties accessing essential health and nutrition services.”
Limited access to health services and the growth monitoring, screening, and treatment for stunting that goes alongside them is another factor contributing to the disparity in the stunting rate between regions.
Maternal health is another cause of stunting, and it is not limited to the time when a woman is pregnant or breastfeeding. It is a problem that can linger throughout generations.
“Stunted children are more likely to be stunted mothers,” Rah said. "And stunted mothers are more likely to give birth to low birth weight babies, who are again more likely to grow stunted. That’s why we say that child stunting actually perpetuates the vicious cycle of malnutrition.”
NEGATIVE IMPACT OF STUNTING ON COUNTRY’S GROWTH
The long-term economic repercussions of stunting for individuals, and the sheer numbers of stunted children, has a significant impact on Indonesia’s economy.
The World Bank estimates that stunting and other nutritional problems lower the gross domestic product by around 3 per cent a year.
Indonesia’s Human Capital Index value has increased, from 0.50 in 2010 to 0.54 in 2020, but this still means that “a child born in Indonesia will only be 54 per cent as productive when she grows up as she could be if she enjoyed complete education and full health.”
The government of Indonesia is battling a long, drawn-out battle in this regard.
Dr Dhian Proboyekti Dipo, director of public health nutrition at the Ministry of Health, told CNA: “Today’s workplace earnings reflect the past 50 years of stunting.”
And this threatens the country’s ability to reach its National Midterm Development goals, established every five years, she added.
“Stunting is a national priority,” Dr Dipo said, noting that the government has an ambitious target of decreasing stunting to a rate of 14 per cent by 2024. “This target aims to support the achievement of the second sustainable development goal, which is to eliminate hunger.”
HOW TO BREAK THE VICIOUS CYCLE
A strong tool to break this cycle comes through more than 1.5 million health volunteers, called kaders, who staff community health posts throughout Indonesia.
The vast majority of these are women who come from the communities in which they serve, providing services like counseling and growth monitoring for mothers and infants, as well as treating common illnesses and providing nutrition advice.
They are the first point of call for ill members of their community, and sometimes call midwives in when the problems are too great for them to handle alone.
Rani Sumarni is one of these midwives. Sitting on the stoop of a small, brightly-painted concrete house in Bekasi and brandishing a small pink booklet, she spoke in a patient, measured voice to the mother that lives there, Saulina Sitompul.
The pink booklet folded out to reveal a chart for tracking children’s growth.
Key developmental markers and immunisation periods are noted, and there are areas for parents to mark down where their child is along the scale. If they’re within the large green stripe, they’re within the ideal weight range. When parents measure weight, they’re also encouraged to measure height.
“She’s short, right?”
“It doesn’t mean that she’s a dwarf,” Sumarni explained. “There’s something called stunting.”
Sitompul nodded, indicating that she has heard of this before, so Sumarni continued her questioning: “Have you ever been given quail eggs, or milk?”
“Yes, I got it from the community health centre.” Sitompul received vitamins, fortified milk, fortified bread, and quail eggs, high in protein and easy to digest, as part of a nutritional supplementation package for stunted children.
The contents of these packages vary among districts and may be partly funded by the private sector, as was the case with the milk that Sitompul received.
Nutrition counselling, nutrition supplementation, and working with the private sector, are just some of the many ways that the government of Indonesia is tackling stunting.
They form part of the National Strategy to Accelerate Stunting Prevention, created in 2017 to finally coordinate the efforts of 22 different ministries, regional government, the private sector, and civil society groups.
Included in the strategy are specific interventions, like nutrition improvement for children in their first 1,000 days of life, and sensitive interventions, like promoting education and community empowerment, with ambitious targets to reduce stunting in all 514 districts in cities by 2021.
An estimated US$14.6 billion was allocated for the strategy.
Dr Gondomartojo of the World Food Programme said: “The government is also committed to widening its social security system … helping the welfare of poor families so that they can pay more attention to the nutrition of children and pregnant women in the household.”
A key way the government is widening its social security is in non-cash food aid, said Dr Dipo, the health ministry’s director, as are “national health insurance, early childhood education actions so that children can grow and develop well, and the Family Hope Programme.”
This programme aims to improve human capital development by providing conditional cash transfers to households, administered by the Ministry of Social Affairs.
This approach proved to be effective. From a rate of 36.8 per cent in 2008, the number of stunted children under the age of 5 had dropped to 30.8 per cent by 2018, and dropped again to 27.7 per cent in 2019.
This trend was borne out at the local level, as well. In August 2018, there were 718 stunted children in Sukadami. By February 2020, the figure went down to 82.
Children are deemed to be no longer stunted if they achieve a height consistent with those of their peers. However, most of the physical and cognitive effects of stunting are irreversible.
COVID-19 HAMPERS EFFORTS
But then COVID-19 hit, and with the pandemic came its own set of challenges.
For many families, this came in the form of a sharp drop in income. Aryati makes her living selling vegetables. But when the pandemic hit and people were urged to stay at home, her customers dwindled.
“Before, I used to sell enough to buy enough food, but not now. Mothers have to be smart in how they respond to a pandemic like this. If we don’t go out to sell, automatically our daily menu gets less and less. Before we had chicken, now it’s tempeh and tofu. Before there was fish, and now we switch it out for something less expensive that can last through until the next week.”
“COVID-19 certainly affects income, purchasing power, food consumption patterns, and ultimately, greatly affects the nutritional status and health of the community,” said Dr Dipo, the health ministry director.
“Without adequate and timely action, the number of malnourished children is predicted to increase by 15 per cent, or about 7 million worldwide.”
Karimah, the vegetable seller in Sukadami, was lucky. Her husband, previously unemployed, managed to find work during the pandemic as a security guard at a local warehouse, which means that their household income, previously reliant on her vegetable sales, has increased.
But she is finding it difficult to access the healthcare that she needs for her daughter.
“The community health posts are closed. If you have an ill child, you have to find a practising midwife, or try to find a private clinic that’s open. But sometimes, because of the health protocols, it’s hard,” she said.
A survey conducted by UNICEF in 2020 found that “more than a quarter of primary health centres across the country delivered less than half or absolutely no essential nutrition services,” according to Rah, the agency’s chief of nutrition in Indonesia.
There is a glimmer of hope, despite the pandemic-imposed challenges of decreasing income and limited access to healthcare, and the closure of schools.
Community health centers remain closed, but the kader health volunteers and midwives like Sumarni continue with growth monitoring and nutrition counseling, door-to-door.
New innovations are emerging as well, like the use of mobile chat groups, which are effective and easy to use in Indonesia, where there are 338.2 million mobile connections - more mobile phones than there are people.
Information, gossip, and breaking news are shared freely and widely over WhatsApp, the most popular messaging app in the country, and Sumarni and other community health workers are using this to their advantage.
She has started using a mobile chat group to communicate with parents, and if a parent reports back that their child is under height or has other developmental challenges, she visits their homes directly. She has also seen mutual aid crop up in these groups.
In her chat group, the local residents started a campaign to promote the consumption of catfish, a popular source of protein in their area. “The residents are sharing (catfish) with each other, from resident to resident. It’s high in protein, and the hope is that it’s a cheap way for us to prevent stunting.”
These signs, albeit small, are certainly encouraging. Health services are doing what they can to adapt to the pandemic and continue serving their communities with nutritional support, education, and growth monitoring.
And although the national budget was reallocated to strengthen the health system to treat COVID, Gondomartojo of the World Food Programme noted that the budget to reduce stunting was not heavily affected. “There was only a small reduction. There is still a commitment here,” he said.
It remains to be seen if this commitment will be borne out by the government reaching its target of reducing the stunting rate to 14 per cent by 2024, or whether the pandemic-induced obstacles may be too great to overcome.
Like many other parents, Sitompul, the mother in Bekasi, fears for their children’s future.
“I worry about my child, but we still have faith. We try not to think about negative things. We just think positively.”
Others in her area are looking in more long-term ways.
Dr Meniarti, Bekasi’s chief medical officer, said: “We all want to eradicate stunting so that the children will become good leaders in the future. Hopefully, much better than us.”