Introduction
A number of recent reviews of crises, including Syria (ENN 2014), Lebanon and the Ukraine (GNC-ENN 2015) have raised questions about the humanitarian nutrition response in contexts where levels of wasting are not elevated or high in terms of emergency thresholds, but where stunting is prevalent.
ENN decided to investigate the implications of operating in situations of protracted crisis where levels of stunting may be high and of concern. This brief investigation included a review of documents and informal discussions with a number of nutrition focal points in some of the donors and agencies1. The purpose is to begin to explore the issues and pose questions and in so doing get the issue of stunting in protracted contexts higher up the nutrition agenda.
The numbers
Globally, an estimated 165 million children under five years of age are stunted (have linear growth failure and are short for their age) at any point in time (UNICEF/WHO/ WB 2015), with more children either being born stunted or becoming stunted in infancy and childhood all the time. Stunting occurring before the age of two is a well-established risk marker of poor child development, predicting poorer cognitive and educational outcomes in later childhood and adolescence (Grantham-McGregor et al 2007, Walker 2007, Black et al 2013, Martorell et al 2010) and in turn hindering economic productivity of individuals, households and communities. Although it is generally emphasised less, stunting is also associated with an increase in risk of death. While lower overall than for wasting, the risk is still 5.5 times that of a healthy child for severe stunting (a higher risk than moderate wasting at 3.4 times) (Olofin et al 2013). When stunting and wasting (either severe or moderate) are combined, the mortality risk rises to 12.3 times that of a healthy child (McDonald et al 2013).
Stunting is a result of multiple risk factors, including maternal age and health status before, during and after pregnancy (Ozaltin et al 2010). Evidence suggests that a substantial 20% of childhood stunting (Christian et al 2013) is pre-determined in utero. Other risk factors include inappropriate complementary feeding (WHO 2015), poor hygiene and sanitation, a high frequency of infections (Prendergast & Humphrey 2014) and poor access to healthcare. Irrespective of its causal pathways, in general stunting is viewed as a chronic problem requiring long-term, development-orientated actions focused on addressing the multitude of risk factors.
However, 45% of stunted children globally (and therefore a large proportion of those children becoming newly stunted all the time) live in countries classified as Fragile and Conflict Affected States (FCAS) by DFID (Last updated in 2013 - see Annex 1). As such, they are exposed to numerous protracted humanitarian crises. Extreme poverty is forecast to become more concentrated in fragile states (Burt et al 2014). Given the links between stunting and income, it is reasonable to assume that the prevalence of stunting could increase in the future (IFPRI 2015). Protracted crises are also becoming the norm rather than an exception. According to the UN Food and Agriculture Organization (FAO) in 2010, 19 out of 24 (79%) countries in food crisis were classified as such for eight of the previous ten years; i.e. were chronic/protracted (FAO 2010).
As illustrated in Table 1 and in Box 1 below, the prevalence levels of stunting in over half of FCAS are, according to the WHO classification, either serious or critical. Furthermore, nearly half of the FCAS countries have levels of severe stunting >15%. Although there is no global guidance on ‘alert’ levels for severe stunting, the associated mortality, which is greater than that reported for moderate wasting (Olofin et al 2013), suggests that a prevalence of severe stunting >15% should be a cause for humanitarian concern.