Guest Host: Allison Aubrey

Shyamkali and her daughter are featured in Roger Thurow's new book about how early nutrition can affect children and communities' futures.

Shyamkali and her daughter are featured in Roger Thurow's new book about how early nutrition can affect children and communities' futures.

The most critical period of a child’s development is from conception through age two. Lack of proper nutrition during this time can cause developmental issues that last a lifetime: cognitive delays, slow physical growth and a compromised immune system, to name a few. The World Health Organization estimates one in four children experiences this type of stunting. Economists say this can cost countries up to 16 percent of their GDP in lost productivity and future health care expenses. These numbers have caught the attention of world leaders and inspired a movement to address maternal and child nutrition. A new book by a Pulitzer Prize-winning journalist tells the story of these efforts.

Guests

  • Roger Thurow Senior fellow of global food and agriculture, The Chicago Council of Global Affairs; author of "The First 1,000 Days: A Crucial Time For Mothers And Children—And The World"
  • Asma Lateef Director, Bread for the World Institute

Read An Excerpt

Reprinted with permission.

The First 1000 Days by wamu885

Transcript

  • 11:06:53

    MS. ALLISON AUBREYThanks for joining us. I'm Allison Aubrey of NPR News sitting in for Diane Rehm. Over the last several years, there's been a lot of research on the social and economic costs of childhood hunger. And with 170 million malnourished children around the globe, the costs are big in human suffering and lost productivity and future healthcare costs. In response, the international community has launched a movement to address malnutrition during the critical period from the beginning of a mother's pregnancy to a child's second birthday.

  • 11:07:23

    MS. ALLISON AUBREYPulitzer Prizewinning journalist Roger Thurow traces these efforts in a new book, "The First 1,000 Days: A Crucial Time For Mothers and Children and the World." He joins me in the studio along with Asma Lateef who's director of the Bread For The World Institute. Welcome to both of you, thanks for joining us.

  • 11:07:41

    MR. ROGER THUROWThank you.

  • 11:07:42

    MS. ASMA LATEEFThank you.

  • 11:07:43

    AUBREYIf you would like to join the conversation, call us, 800-433-8850, or send us an email, drshow@wamu.org. You can also find us on Facebook or send us a tweet. Roger, I want to start with you. As I read your book, one paragraph really grabbed me. I want you to read it for us, if you will, because I think it really just lays out the issue so well. It's right there on page 7.

  • 11:08:09

    THUROWAbsolutely. Thank you. "If we want to shape the future, to truly improve the world, we have 1,000 days to do it, mother by mother, child by child, for what happens in those 1,000 days through pregnancy to the second birthday determines, to a large extent, the course of a child's life, his or her ability to grow, learn, work, succeed and by extension, the long term health, stability and prosperity of the society in which that child lives."

  • 11:08:39

    AUBREYWow. That is just a really powerful thought, I mean, that so much is determined at such a young age, right, Asma? Asma, there's a whole body of evidence, I gather, documenting what's happening during the first 1,000 days of life, why they're so important to brain development and overall development. But the international development community, I gather, was not very focused on this issue until recently. You say that back in 2008, a series of papers published in the medical journal, Lancet, helped to raise awareness. What did these papers say?

  • 11:09:17

    LATEEFThank you. The papers were really game-changing because they really focused on the damage that was done by malnutrition, as you say, to individuals and to economies. They focused on a target population, pregnant women, mothers, lactating mothers and babies and kids up to the age of 2. They focused on a target set of countries, the countries that had a very high burden of malnutrition within that target population.

  • 11:09:51

    AUBREYAnd they said what? This is a huge problem, right?

  • 11:09:53

    LATEEFRight. This was a problem because you were losing so much in terms of individual productivity. And also, you know, malnutrition actually kills. So the Lancet series focused on the impact on child and maternal mortality, but then also for children who survive, they lost educational capacity, health productivity as they grow older...

  • 11:10:21

    AUBREYEverything the society loses.

  • 11:10:22

    LATEEFAbsolutely. And they pointed to a set of cost effective and evidence-based solutions, things that were actionable and could be scaled up almost immediately.

  • 11:10:33

    AUBREYGot it. So we will get to some of those solutions, but Roger, I want to talk about what happens when children don't get the nutrition that they need during this critical period. You write that millions of kids around the globe are stunted. And in your book, I noticed this picture from Guatemala. There's a 2-year-old and a 4-year-old sitting side by side, right next to each other. They're siblings. The 2-year-old, to me, looks really robust. The 4-year-old looks very small. How does this photograph from Guatemala tell us the story of stunting and what is being done to address it.

  • 11:11:07

    THUROWYeah, you're right, Allison. It's really revealing. And kind of in the process of the reporting and following these moms and children in India, Uganda, Guatemala and Chicago to kind of draw global comparisons, but then also to show the commonalities and things. And you really see the impact of stunting. And in this photo and in this example of Maria Estella, she's one of the moms in Guatemala that I follow, her first child, Jessica, as Jessica's developing and growing or not growing and she's worried about is this child thriving.

  • 11:11:42

    THUROWYou know, the developmental markers that a mom just instinctively knows, so kind of how a child is reacting to things, when they start walking, when they begin talking, how they're eating, noticed that Jessica just wasn't thriving, that...

  • 11:11:55

    AUBREYSomething was off.

  • 11:11:56

    THUROWSomething was off. So then, she hears about a clinic -- it was an abandoned mission clinic, abandoned during the long war in Guatemala, that some American students, medical students, and Guatemalan students, they rehabilitated. They named it Primeros Pasos and they then basically went to work in the communities that had long been abandoned. These are communities in the Western highlands where...

  • 11:12:22

    AUBREYSo way up in elevation from Guatemala City.

  • 11:12:24

    THUROWExactly.

  • 11:12:25

    AUBREYUp that windy highway.

  • 11:12:26

    THUROWPrecisely. And largely Mayan communities, largely disenfranchised, marginalized...

  • 11:12:37

    AUBREYSo very isolated people.

  • 11:12:38

    THUROWExactly. And they're the -- the child malnutrition rates and the stunting rates are upwards of 70 percent.

  • 11:12:43

    AUBREY70 percent.

  • 11:12:44

    THUROW70 percent. So everyone you see is stunted. And stunted children become stunted adults. So Maria Estella, she's worried about Jessica, her first child. Primeros Pasos is starting nutrition rehabilitation course where they're gathering moms already in their pregnancy and say, here's the important things to be eating, a diversified diet, why these minerals and vitamins are so important, these nutrients, so important already beginning in the mom's pregnancy, cooking classes in the proper way to use these.

  • 11:13:14

    THUROWAnd then, so she registers for that and says, I'm pregnant again. What can I do better for this second child. Second child was Jorge. He's born robust. He's a big child. Everybody in the community is like, wow. Look at the size of this baby.

  • 11:13:26

    AUBREYBig kid.

  • 11:13:27

    THUROWA big baby, kind of the prize baby that's born. Everybody's kind of paying attention. Jorge, then, really developing, thriving through, you know, the breastfeeding with the mother, then the complimentary food. So by the time he's 2, and what this picture shows is, here's Jorge, he's 2 years old. He's basically, you know, the same size as his sister, who's almost two years older. They kind of weigh the same. Jorge, a little bit less. They're basically the same size.

  • 11:13:52

    THUROWAnd what that shows is it doesn't have to be kind of waiting for a generational change. This is something that can change with better nutrition, the reducing of the stunting, the breaking of this pattern that just goes through societies and families and generations. It can be done between children. And this concentration on proper nutrition, then everything that supports the nutrition so also with that is proper water, better water, sanitation, hygiene.

  • 11:14:18

    AUBREYThe basics, the very basics.

  • 11:14:19

    THUROWExactly. The healthcare infrastructure, all so important and Maria Estella realizes this and this comparison of these two children shows this is what's possible when one really concentrates of 1,000 days of particularly nutrition.

  • 11:14:30

    AUBREYGot it. So Asma, you hear this story. These are very simple interventions, sort of basic cooking, basic hygiene. Is this happening around the world? This is a lovely example in Guatemala. Where else are we seeing this focus on giving mothers-to-be just very basic guidance, education, simple -- help with just simple matters to help improve nutrition for their child?

  • 11:14:53

    LATEEFWell, in -- since, you know, this growing awareness about the 1,000 days and through the Lancet interventions, there has been an effort to begin to bring these things to scale. One of the challenges, though, is while there has been growing commitment, political commitment, there hasn't been as much commitment of resources. And so it is, you know, one of the very compelling things about Roger's book is in -- many of these women have children prior to the ones that he's following and it's an accident of birth in a way that some of these children are being born at a time where there is this growing awareness.

  • 11:15:37

    LATEEFAnd governments and health workers and, you know, the NGOs that are working in those areas are taking action. But for too many children, they are still -- too many mothers and children are still not receiving the kind of help that they need.

  • 11:15:56

    AUBREYGot it. Roger, your book takes us to four different countries to reveal what this first 1,000 days, I guess I'll it a movement, looks like. You introduce us to women in Uganda, India, Guatemala and then I got to the chapter of Chicago. Whoa. All of these women are pregnant when you meet them. What do pregnant women in Uganda, India and Guatemala have in common with pregnant women in the south side of Chicago?

  • 11:16:22

    THUROWThe reason why I wanted to do some place in the United States and then in Chicago for various reasons is to show that, look, this isn't just a problem that's over there somewhere for American readers. It's not just a problem that, you know, we can kind of isolate, it's there, and maybe not worry about or focus on, but it's really important here of what goes on in those 1,000 days. And so what's really interesting is that as you see kind of the nutritional education and kind of the hygiene and these wash issues, the terminology -- the languages are all different, of course, in these places and the settings and the backgrounds.

  • 11:16:58

    THUROWBut the information, the material is the same everywhere. And that was remarkable, that whether it's a midwife in Uganda or a doula in Chicago or the community workers out of Aranda in India or in a community center in Guatemala, the language, the terminology they're using, the importance of the vitamins, the importance of these 1,000 days -- and all the doulas and the midwives and the community workers were addressing the pregnant mothers and they were basically saying, look, your child can achieve great things.

  • 11:17:30

    AUBREYSomething they probably didn't expect to hear.

  • 11:17:32

    THUROWExactly. Or would be a preposterous thought in many of these places, given the background, just the socioeconomics there. But your child can achieve great things and whatever you're aspirations are for these children -- universally it's I'd like this child of mine to have a good education. Right. To have that good education, it's really important what happens already in pregnancy 'cause that's where the cognitive development happens.

  • 11:17:52

    AUBREYStay with us. More of our conversation coming up after a short break. I'm Allison Aubrey of NPR News sitting in for Diane Rehm.

  • 11:20:02

    AUBREYWelcome back. I'm Allison Aubrey of NPR News sitting in for Diane Rehm. I'm joined in the studio by Roger Thurow, a senior fellow at The Chicago Council on Global Affairs. He is also the author of the new book, "The First 1,000 Days: A Crucial Time For Mothers And Children -- And The World," also by Asma Lateef who is the director of the Bread for the World Institute.

  • 11:20:24

    AUBREYRoger, I want to talk about a paradox here, the idea of serious malnutrition in areas where there's often an abundance of food grown. In Guatemala, you paint a land where these nutrient-rich vegetables that are grown there fill the shelves of our stores. We buy these vegetables that Guatemalans grow. Yet where, there, they can't afford the things they're growing. The child stunting rate, as you pointed out, approaches 70 percent in parts of the country. Talk about this paradox.

  • 11:20:52

    THUROWYeah. You see the paradox in all the place that I'm -- that -- where I followed the moms and the children. And basically you could extend that to places all over the world. In India, for example, India is the world's leading producer of milk. I think it's the second-leading producer in the world of fruits and vegetables. But yet nearly half of the children in India are malnourished. They have more malnourished children. They have more children born every day, more 1,000-days journeys begin in every day -- in India every day, and then, kind of, then the highest absolute number of malnourished children. They're making some progress.

  • 11:21:26

    THUROWIn Uganda, I mean a country that you would always think of, you know, you put a stick in the ground and it'll grow because of the kind of the abundance and the richness there and kind of the Nile River that runs through the country. Guatemala, as you point out, this paradox -- kind of this paradox of globalization and all these -- and not just kind of normal-sized vegetables but jumbo-sized vegetables. I mean, the carrots that you see would basically make Bugs Bunny cry.

  • 11:21:50

    THUROWI mean, they're so big. And the radishes the size of softballs. But most of that goes to export or domestic markets. And then the moms themselves that may be in the fields harvesting these crops...

  • 11:22:03

    AUBREYThey must be saying, I can't afford these things.

  • 11:22:04

    AUBREYI can't afford these things. So that's part of the educational message is, keep some of these at home. They don't all need to go to export because the most important thing is your children, it's your grandchildren, it's your relatives that -- of the people on the farm. And then, in Chicago, of course, to moms basically living and growing up -- and the children growing up in the shadow of the Board of Trade, where commodity prices are set, you know, for crops around the world...

  • 11:22:28

    AUBREYThey're in the bread -- near the breadbasket of the world.

  • 11:22:30

    THUROWBreadbasket of the world. You go just, you know, miles outside of Chicago and you're driving through some of the richest farmland and most productive farmers and technologically efficient farmers in the world. And yet, you know, the malnutrition -- so what you're seeing in Chicago, which is then representative of places all across America, both rural and urban, is the malnutrition then manifested in our skyrocketing obesity rates and overweight. And so at one stage in Chicago, basically 20, 25 percent of children, when they were entering kindergarten in the Chicago Public School System, were already overweight and obese.

  • 11:23:05

    AUBREYAnd you introduced us to a woman in the book who, you meet her as she's pregnant and she sort of owns up to the fact that some of her favorite foods are Cheetos and Snickers. This feeds into a question that we have coming in on the phones. I'm going to open the phones now. This is Colby in Myrtle Beach, S.C. Colby, you are on the air.

  • 11:23:25

    COLBYHi. I was hoping you guys could speak specifically to the issue of food deserts and more in particular its ubiquity across the rural-urban divide and how class, race and history all inform that. If you could, just give a quick sketch of how that phenomena arose.

  • 11:23:42

    AUBREYFood deserts.

  • 11:23:43

    THUROWYeah. So Chicago was one of the first -- the first large city to be mapped for food deserts. And what that showed is this crucial relationship between the availability of fresh foods -- of these vital nutrients and minerals in fruits and vegetables, meats, dairy products, that are fresh, and then the imbalance in those communities then of maybe the inaccessibility or unavailability of those foods, but then a readily available fast foods. So kids getting -- moms, kids, families basically buying their foods in liquor stores or gas stations or fast-food places as opposed to, you know, regular grocery stores that then would have an abundance of this.

  • 11:24:29

    THUROWYeah. And you're absolutely right. So then all the socioeconomic conditions that are present there -- Rahm Emanuel, the mayor of Chicago, they had -- he was kind of a speaker at the launch of the 1,000 Day Scaling Up Nutrition movement domestically and in Chicago back in 2012. And he said, so, when he looks at food deserts, yes, there's a nutritional component for them. But he says, when I see food deserts, I see their opportunity deserts. Because where there's a food desert, there's a job desert, there's a security desert, there's a health desert, there's an infrastructure desert, there's an education desert. So all...

  • 11:25:04

    AUBREYLots of needs there.

  • 11:25:05

    THUROW...yes, so all those things that you mentioned are then come to bear and fruition in these food deserts. And then breaking the food deserts isn't as simple as, okay, so there's -- the Walgreen's all of a sudden is now offering fresh fruits or more vegetables, so there's more food available. there. Or even if Whole Foods store is open or a farmer market comes...

  • 11:25:25

    AUBREYThat doesn't change behavior overnight.

  • 11:25:27

    THUROWExactly. Or what the demographers might miss then is, okay, oh, those things come in, food desert broken. But because there's all these just lines in the communities -- there may be gang lines, particularly on the south side of Chicago where the violence was escalating rapidly and dramatically in the 1,000 day period where I'm following the moms there. You know, it may be a dangerous -- a risky proposition then to go to these places to get them.

  • 11:25:49

    AUBREYSo these moms afraid to go out to the store.

  • 11:25:52

    THUROWYes. So Jessica, one of the moms, you know, her doula, they're talking about here's the foods, the diversified foods, here's the vegetables and things, and here's where you can buy them and, again, the cooking classes and how you can prepare them. And she says, so Jessica -- and she was six, seven, eight months pregnant at the time -- are you doing your exercises, as we talked about? So exercising also so very important. And Jessica says, well, I was. What do you mean you were? Well, my mom saw a couple of men with guns on our street.

  • 11:26:16

    AUBREYAh.

  • 11:26:17

    THUROWAnd she says, you're not walking anymore. And that was her main form of exercise.

  • 11:26:19

    AUBREYSo that intimidated her.

  • 11:26:21

    THUROWExactly. And so, again, so it's just knowledge. So what I found -- and, again, you were asking kind of the comparisons of moms everywhere that I was following -- I found that the most common craving of moms during their pregnancy and then for new moms is for knowledge. And knowledge is power, as we say. And you can see their eyes light up when they're getting this nutritional information and the hygiene information and, you know, kind of the exercising and all that goes into the 1,000 days. But then, if you're not able to put that knowledge in to play, that knowledge becomes a burden.

  • 11:26:52

    AUBREYSo poverty may trump that knowledge.

  • 11:26:54

    THUROWExactly. So poverty then -- again, in all these places that I was doing the reporting -- poverty is then this big trump card. So it shows this kind of need for integrated development both abroad and in our own communities. It's not just one issue. So it's not just, okay, breaking up the food deserts, that it's all these other things that then come into play for the moms to put their knowledge into play in the 1,000 days.

  • 11:27:16

    AUBREYWe have a couple of questions about breast feeding. We have a tweet that says, please talk about the importance of breast feeding and the infamous history of what formula has done to developing countries. There's also another call about breast feeding. Monica from San Antonio, Texas, you are on the air, Monica.

  • 11:27:34

    MONICAHi. How are you all?

  • 11:27:36

    AUBREYGreat, how are you?

  • 11:27:39

    MONICAVery good. Just a quick thing about what you were just talking about. My brother taught people in Guatemala how to fish with the Peace Corps. And as soon as the Peace Corps left, they stopped fishing, because it's not traditionally something that they do.

  • 11:27:48

    THUROWHmm.

  • 11:27:49

    MONICASo that was an interesting thing. But there is -- I was reading about an illness and I can't remember the name of it -- I was looking for it online when I was talking to you all -- when I was listening to you -- where you have a mother and she has a baby and she's breast feeding it, and a year later she has another baby. She stops breast feeding the first one to be able to feed her now infant child, and the second child -- the first child that was born is now malnourished and he has the same things, the stunted growth and things, because he's not getting anything to replace what he was getting with the breast milk. Does that have anything to do -- to play in this field?

  • 11:28:28

    AUBREYSo, Asma, let's see if you want to take that question, breast feeding. When women have children sort of back-to-back, what that does to the older child.

  • 11:28:35

    LATEEFYes, it's really important. One of the things that the Lancet Series really pointed out was how critical breast feeding -- exclusive breast feeding is in the first six months. And then shifting to a breast feeding and complementary -- appropriate complementary feeding is really important. The suboptimal breast feeding is linked to child's deaths and it puts children at increased risk for pneumonia and diarrhea, which also can lead to death in early childhood.

  • 11:29:08

    AUBREYAnd are breast-feeding rates going up in some of these places that you document, Roger?

  • 11:29:12

    THUROWThey are because, I think, there's greater awareness of this. The people in the communities are talking about this. But what the caller refers to is it's really important that, you know, whether it's kind of a medical issue or just kind of the pattern of having children, but in a lot of these places, it's also a cultural thing. That even when you become pregnant with another child, then you'll stop breast feeding the child. And I saw that in a number of places. But then there's just also other cultural things.

  • 11:29:36

    THUROWSo in the area of India, in Uttar Pradesh -- one of the northern states and one of the poorer states and one of the ones most troubled by malnutrition and stunting -- there it was just common practice and just kind of in the culture, this is the way that things are done, is that the first breast milk was discarded.

  • 11:29:55

    AUBREYAh.

  • 11:29:56

    THUROWAnd the first breast milk...

  • 11:29:57

    AUBREYThe most nutritious type, they tell you when you give birth.

  • 11:29:58

    THUROWExactly. Precisely, with the antibodies-rich colostrums that basically really sets the child up for this strengthened immune system.

  • 11:30:05

    AUBREYAnd why was that thrown out?

  • 11:30:07

    THUROWIt was because they thought it was part of the afterbirth, it was dirty, it was polluted in a sense.

  • 11:30:12

    AUBREYSo just cultural reasons.

  • 11:30:13

    THUROWExactly. And so they had a lot of things that were going on kind of for just purification issues or warding off evil spirits in that crucial period after birth. A lot of times the baby was just set aside after birth while they tended to the mother. And so they had huge problems with hypothermia, with infection rates. And in that area, their infant, their first-day, and infant first-week, first-month child mortality rate was like 85 or 90 children per 1,000 live births, which is really high.

  • 11:30:45

    AUBREYMm-hmm.

  • 11:30:46

    THUROWAfter 16 months, 18 months of these behavioral change, immediate breast feeding, the skin-to-skin contact with the baby on the mother's chest, right away after birth, they brought -- they basically cut those mortality rates in half.

  • 11:31:01

    AUBREYWe have a call from Cynthia in St. Louis, Mo. Cynthia, you're on the air.

  • 11:31:07

    CYNTHIAHi. I am a stay-at-home mom and I'm a volunteer advocate with an organization called RESULTS. And I've been working to urge my representatives and senators to support the Reach Every Mother, Child Act, which would promote maternal and child health, best practices like the nutrition you're talking about and vaccines, things like that. I was wondering if you and your colleague, Asma, if you could comment on the importance of average Americans speaking out on these kinds of issues and what they can do.

  • 11:31:36

    AUBREYAsma.

  • 11:31:38

    LATEEFI think, you know, thank you so much for bringing that up and thank you for the work that you're doing because RESULTS is a terrific organization. It's really important, I think, for average listeners, to everyone to speak up. Because, as Roger's book really shows, that nutrition is foundational. And it -- the absence or the lack of or suboptimal nutrition in this critical 1,000 days undermines investment in every other area -- in the area of education, in the area of infrastructure, you know, the future, building the future. And so it's really important that we really help people understand why this is such a critical time and the fact that we do know what to do.

  • 11:32:28

    LATEEFAnd in this country, there are -- I mean, we were just talking about breast feeding. Breast feeding can be supported by policies -- and policies that provide guidance on when it's appropriate to promote breast-milk substitutes and when it's not and providing guidance to the health sector about information about breast feeding, to encourage women to breast feed, but then also creating the space for women to breast feed.

  • 11:32:55

    THUROWMm-hmm.

  • 11:32:56

    LATEEFYou know, we don't have a maternity leave policy in this country. And women -- so how do women find the time. I mean, if you have the personal resources to stay at home for those six months to do it, then you can. But if you don't...

  • 11:33:11

    AUBREYSo it's one thing that they do it and another thing to help women, support women to do it.

  • 11:33:14

    LATEEFSupport, yes.

  • 11:33:16

    AUBREYSo, I'm Allison Aubrey of NPR News. You're listening to "The Diane Rehm Show." If you'd like to join us, give us a call, 800-433-8850. Or send us an email, drshow@wamu.org. We are going to open the phones here. We have Janet from Denver, Colo. Janet, you're on the air.

  • 11:33:36

    JANETHi. Thank you so much for the show.

  • 11:33:39

    AUBREYSure.

  • 11:33:40

    JANETI am currently a volunteer with a backpack program that gets food to children over the weekends who don't have enough food at home. I also just recently finished my Masters in Public Administration and studied abroad, public health issues in both Uganda and Cuba, so I certainly saw a lot of what you are discussing. My question is, I'm wondering if you can comment on the issue or the importance of not only educating mothers-to-be and mothers of small children, but the people and specifically the women who surround them -- the grandmothers, the aunts, the siblings -- who can encourage them to go out to the walk around the neighborhood or make sure they're getting the food.

  • 11:34:25

    JANETI think if you just educate the mothers, they may struggle with customs or traditions in their family if the whole network isn't onboard.

  • 11:34:35

    AUBREYGot it. So, Roger, the whole network. Speak to this.

  • 11:34:37

    THUROWYeah. You're absolutely right. That's a really good point. And I saw that everywhere. The education not only for the moms but hopefully also brought into those community discussions under the home visitation programs. The mothers-in-law are really important in a lot of these places. I saw that really in India and Uganda and -- well, in all the places. Because the mothers-in-law, they'll be saying, you know, well, this is the way I did things. Why do we have to do it this way? And so to get them onboard is really important, the dads, all the caretakers.

  • 11:35:08

    THUROWAnd the dads particularly because, in Guatemala, it's the moms who are really reliant on their husbands to basically be giving them the amount of money to spend every 15 days, every month, every week, whenever they would go to the market, it would be, well, here's this much that you can spend on the shopping and on the food shopping. And if they realize that, no, it's really important that, when your wife is pregnant, she really needs this -- these added nutrients and the food is really important for her. So to bring the dads in. And in the book, there's particularly one of the days, Rajender, he's the husband of Shyamkali, his...

  • 11:35:41

    AUBREYThat's the woman who has five children or about to have five children.

  • 11:35:44

    THUROWRight. We don't want to give away too much of the book. But she has -- so she has four children and they're all daughters. And the desire of many Indian families, particularly in the rural areas, would be to have a boy. And so every one of her children was basically conceived to be a boy. And then, so, we meet her kind of in her pregnancy and then she has the child -- and the fifth child, that is also a girl. And her husband, who's away working in New Delhi on day jobs, he, kind of refusing to take the mom's calls on the cell phone. He gets word that it was another girl that was born. He cancels plans to come back.

  • 11:36:23

    AUBREYSo clearly he's disappointed.

  • 11:36:24

    THUROWHe's clearly disappointed. And then the mom is saying, look, I realize -- I love all my girls. And a really poignant moment then in the reporting as she's explaining the birth, and it's in a clinic that's really, you know, kind of run down and Spartan in terms of just any kind of modern-day equipment there. So she gives birth on the floor, laying on a blanket that's marked with blood stains because the one delivery bed was already occupied. She gives birth and the first thing that she hears -- she hears a child crying -- and then the first word she hears is from the midwife or from the birth attendant that says, I'm sorry.

  • 11:37:06

    AUBREYAh.

  • 11:37:07

    THUROWAnd the mother is -- and Shyamkali, the mother is like, well, I hear the baby crying. I think everything is okay. And then the midwife then turns to the other moms there who are waiting to give birth and she says, this mother has just given birth to her fifth daughter.

  • 11:37:19

    AUBREYWow.

  • 11:37:20

    THUROWAnd Shyamkali's, I love all my girls. I'm not disappointed myself. But I'm realizing that the more children I have trying to have this son, how deeper in poverty we become. How are we now going to educate, feed them...

  • 11:37:31

    AUBREYYes.

  • 11:37:32

    THUROW...clothe them through the years? And so the father then eventually realizes, okay...

  • 11:37:35

    AUBREYThat's it. Yeah.

  • 11:37:36

    THUROW...that's it.

  • 11:37:37

    AUBREYComing up, your calls and questions. Stay with us. We'll be right back.

  • 11:40:01

    AUBREYWelcome back. I'm Allison of NPR News, sitting in for Diane Rehm. We are talking about Roger Thurow's new book, "The First 1,000 Days: A Crucial Time For Mothers And Children—And The World." We're going to open the phones. We have a call from Annette in Washington, D.C. Annette, you're on the air. I take it you want to talk about biofortification.

  • 11:40:21

    ANNETTEYes, first of all, Roger Thurow has done this wonderful job in telling this story of hidden hunger, you know, globally, including in the U.S., and I'm wondering if he could just tell us a little bit about how biofortification can help address the problem of micronutrient deficiency.

  • 11:40:41

    AUBREYBefore you start that, Roger, I want to point out that one of my favorite scenes in the book was you're in Uganda, you introduce us to the woman, Esther I believe is her name, and some of the others in her village. And Esther is growing this very special kind of new sweet potato, and she's very proud of it. And I gather the whole community is sitting around talking about it. They're sort of gushing with pride about this new sweet potato, and an 87-year-old woman chimes in, oh, this sweet potato gave me my vision back, she's sort of making the connection between the Vitamin A in the sweet potatoes. That almost sounded too good to be true. Is this a true story? Was she exaggerating here?

  • 11:41:16

    THUROWWell, see that -- and that's a great point. So you hear these stories, and you figure nah, okay, they're exaggerated, or they're apocryphal or something, but then you hear these stories kind of more and more from other people in the community, maybe they're not even sitting each other, so they're not feeding off each other. You go to another community where they're starting to grow these crops, and you hear the same -- the same thing.

  • 11:41:35

    THUROWSo it's kind of the cumulative, you know, weight of these anecdotes, and as a journalist, so that's kind of what I'm dealing with is people telling me their stories and their anecdotes of life and things. And so with the -- so they've started to plant, under this biofortification program the caller referred to, orange-fleshed sweet potatoes, which are rich in Vitamin A, and then...

  • 11:41:54

    AUBREYAnd so those are made just by breeding different sweet potatoes and getting Vitamin A from -- naturally from the plant, through cross-breeding.

  • 11:41:59

    THUROWExactly, precisely.

  • 11:42:00

    THUROWExactly, and so the orange sweet potatoes, which we're familiar with here, so on our Thanksgiving tables, so in places like Africa and elsewhere in the developing world, the sweet potatoes they normally eat are yellow or white. So they're -- they don't have much nutrients in. They're carbohydrate-rich, you know, plenty of energy.

  • 11:42:20

    AUBREYPlenty of calories but not too much nutrient density.

  • 11:42:22

    THUROWExactly, and so by introducing these orange sweet potatoes that have the beta-carotene, so from the orange, the carrots, the Vitamin A.

  • 11:42:31

    AUBREYThe Vitamin A.

  • 11:42:32

    THUROWThat -- that's a staple crop to eat. There are also in Uganda, then, these moms are growing high-iron beans. So beans have an iron content in it, already have some iron, and so through biofortification, it's conventional breeding, so it's not genetically modified, you're not bringing in outside organisms.

  • 11:42:48

    AUBREYSure.

  • 11:42:49

    THUROWYou're raising the nutrient, vitamin, mineral content that's already in the plants and the crops themselves. And so you just raise the iron content. Vitamin A and iron, extremely important in these 1,000 days -- in this 1,000-day window. And so what biofortification does, and as Asma was talking about the Lancet series and the recommendations in there, one was to bring agriculture and nutrition more together.

  • 11:43:09

    THUROWThere had been this gap that grew between, agriculture basically raising yields and incomes of farmers, nutrition then kind of being on the consumer side and the ones that are eating the foods, but they weren't brought together that much. So biofortification brings together and the theory being look, can we get the plants and the crops themselves, these staple foods that these people are eating three, four, five times a week, almost every day, if we can raise the nutrient content of those, then the...

  • 11:43:40

    AUBREYThe overall diet gets better.

  • 11:43:41

    THUROWThe overall gets better, we don't have to rely so much on the supplements or other fortification measures, which are also really good, but in these places the delivery system is uneven, the moms getting these things like the iron and the folic acid supplements that you should take...

  • 11:43:58

    AUBREYThey're often deficient.

  • 11:44:00

    THUROWThey're deficient when they're not going for their prenatal checkups as regularly as women do here and in the richer precincts of the world. So by getting the plants to do some of this work for and the crops and the staple foods, that's one of the ways and one of the really interesting and innovative kind of solutions that's...

  • 11:44:16

    AUBREYGot it. So I was going to talk about bringing agriculture and nutrition together. Farmers often talk about, you know, when it comes to feeding more people, feeding a growing planet, you will often hear talk of yield, just grow more food. But what I hear Roger saying is that a little bit of a new focus on growing more nutrient-dense food. Is that right?

  • 11:44:34

    LATEEFYes, and it's really more important because a lot of the smallholder farmers are women, and so these are the women who are growing the food. They're also preparing the food and taking care of their children. So it's a huge opportunity to bring together increased yields, which brings income to the family that can help the family afford more nutritious food, but it's also helping these women understand, as Roger said, that they should be growing the right kinds of food and keeping some of that food for themselves and for their families.

  • 11:45:09

    LATEEFYou know, nutrition is one of these issues that has traditionally fallen between the cracks. You know, the agriculture sector thought of it as a health issue, you know, micronutrients, take a pill and you'll get your nutrition. And on the health -- on the food side, they -- on the health side they thought it was a food issue.

  • 11:45:31

    AUBREYSure, everyone living in their own silo. We see that a lot, yeah.

  • 11:45:32

    LATEEFAbsolutely, and what's been really I think tremendous over the last several years is this growing understanding that we really need to think about nutrition cross-sectorally and integrate the way we're thinking about it across health programs, across agriculture programs, across education, around women's empowerment issues. All of these things are connected and will yield much better results.

  • 11:45:58

    AUBREYInteresting. We have an email here from Frank from Bedford, New Hampshire. He writes, the one issue I have not heard mention is population growth. Africa's current population of 1.1 billion is projected to quadruple to over four billion people in this century. He says intelligent contraceptive use is critical to helping humankind feed all of its people. Respond to this, Roger.

  • 11:46:22

    THUROWYeah, thanks, Frank, for that -- for the email and the thoughts in raising this issue. I also found this in most of the places that we're going to or most of the conversation with the moms is they would talk about, say, other -- when I was there with other -- with community workers, they'd be asking about contraception. Can you bring me something so -- and they would just talk in very terms that I don't have so many children, I don't have another child.

  • 11:46:48

    THUROWAnd Shyamkali, who I was mentioning with her fifth child, after that she says, you know, that's enough, I don't think we should have any more children because we can see what that's doing to us, kind of the impoverishment. And I think that's a key note kind of on the overpopulation issue or question is that a lot of these families instinctively know that. There's kind of cultural pressures and things, so these issues of kind of behavior change and kind of the education that goes along with that because they are seeing -- you know, it's one of the thing that I hope kind of readers take away from the book is this realization that stunting is this life sentence of underachievement and underperformance, and the costs roll throughout society.

  • 11:47:26

    THUROWIt's the individual and what -- we've talked about that, kind of the cognitive stunting, the lack of performance in school and what they learn and then in their job capacity and earning capacity later in life, but the impact that that has on families. It makes the climb out of poverty that much steeper when you have malnourished and stunted children and the more of those children that you have.

  • 11:47:45

    THUROWAnd so these moms are realizing that just kind of as they watch their families grow, they, themselves, are asking the questions, and the dads, how are we going to feed, educate, thrive as a family.

  • 11:47:59

    AUBREYSure, so stunting really a life sentence for underachievement, as you point out. We have another call here from Rose in Fairfax, Virginia. Rose, you're on the air.

  • 11:48:10

    ROSEYes, thank you for the beautiful discussion. I spent quite a bit of my time, my life, working in this area. And you talked about traditions and taboos, and one thing that's really big in the communities is also, apart from talking to the husbands and the mother-in-law, talk to the community leaders, who really wielded a lot of power in trying to change the behavior and in order to get some of the facilities, like just as simple as having a birth plan in place so that before birth you're planning for that 1,000 days, for the 1,000 days to be successful, you're also planning for the woman to actually get to the clinic because if they don't get to the clinic, they may die before they get there.

  • 11:48:54

    ROSEI wonder, you know, can you expand a little bit on that and sort of at least people can know about the importance of planning before, making sure that the maternal nutrition is good before so that the outcomes after are much better. Thank you.

  • 11:49:14

    AUBREYSure, Asma, sort of simple planning, how is that taking shape around the world?

  • 11:49:19

    LATEEFThank you for that question, and community leaders are really important. Many of them are setting the norms, the social norms in communities, and so the more that they understand the importance, that this is really an investment in their community in the long run, the better it is for women who are navigating all these complicated social and cultural norms. And so it's -- you know, I was recently in Zambia and met with a group called the Saving Mothers Action Groups.

  • 11:49:53

    LATEEFThese were smallholder farmers who had been trained about the importance of getting mothers to -- pregnant women to the hospital in a timely way. And some of them were men, some of them were women, and I asked the men, well, why did you join this group, it seemed strange.

  • 11:50:11

    AUBREYNot something a man might want to do.

  • 11:50:13

    LATEEFRight, and they said, once we knew this, once we had been trained on this, it seemed critical. And so men sometimes -- so these men often found themselves in the place of really being able to engage the community leaders, who tend often to be men. And so that was an approach that was really helping to change the perspective of these community leaders.

  • 11:50:40

    AUBREYA good example. We have an email from Mary. She says, what does Roger think about organizations or NGOs that give nutritional supplements to children in the third-world countries as opposed to providing nutritious food? It seems like an easier thing to transport and a cheaper option of getting more nutrition to more kids. What do you think of the effectiveness of this?

  • 11:50:58

    THUROWYeah, I think it's also really important, and that's a good question, too. It's like all these things, I mean, if you consider, they're all like, you know, arrows in a quiver of the weapons that we need to attack this. So even the people on biofortification and merging agriculture and nutrition more, they realize that that -- that's only one thing, and it's one of the solutions. But the supplementation, you know, that you're talking about, that Vitamin Angels for instance does, the Micronutrient Initiative, you know, you're in clinics.

  • 11:51:34

    THUROWAsma and I have been there, kind of clinics far out in the bush or in really remote, rural, very poor areas, and there you see these bottles or these vials with the Vitamin A tablets or the capsules provided by Vitamin Angels or Micronutrient Initiative, the iron, the folic acid, the -- and then the kind of HIV/AIDS medication and malaria medication. All these things are then so really important. And so if they're there and present in communities, hooray for that and all the efforts done to get them further out, away, because these governments in these countries, the health budgets are so always under pressure.

  • 11:52:14

    THUROWThere's not enough money to begin with, and then those are the budgets that are usually raided for, you know, other aspects that come up. You know, corruption is usually kind of really big. That hits -- it's also in the health ministries and drains these budgets. And so these additional supplement fortification efforts are also really vital.

  • 11:52:32

    AUBREYI'm Allison Aubrey of NPR News. You're listening to "The Diane Rehm Show." We have a call from Sara in Sharpsburg, Maryland. Sara wants to know about services like doulas. Sara, you're on the air.

  • 11:52:47

    SARAOh, right now?

  • 11:52:49

    AUBREYYes, right now, you're on live.

  • 11:52:51

    SARAI am a birth doula and a midwife assistant, and my area is semi -- kind of rural, and there's a lot of suburbs surrounding it. And what I'm seeing in my area is things like traditional foods and traditional healings being sort of outsourced to, like, experts. So postpartum doulas rather than women in the family and communities being really spread out and so that sort of web -- like everything is very expert and nutrition, which nutrition is great, but, you know, experts are sort of taking that community role.

  • 11:53:29

    AUBREYAnd they're expensive, I'm imagining.

  • 11:53:32

    SARAYeah, so yeah, so only, you know, like white, wealthy, wealthy-ish women can afford them. And then everybody else is kind of left in the dust. And simple, like, common knowhow, I guess, and women supporting women is being, like, turned to experts, which I feel like just is really bad.

  • 11:53:51

    AUBREYGot it, got it, very interesting point. Thanks so much for that call. So Roger, take us back to Chicago, where a lot of, you know, how a woman goes through birth is sort of culturally determined. You sort of do it the way the people around you, an aunt or a mother did it. Talk about this point that the caller makes.

  • 11:54:07

    THUROWYeah, it's also a really good point, and thanks for raising that, is it Sara, and thanks for your work that you're doing.

  • 11:54:11

    AUBREYYes, Sara.

  • 11:54:14

    THUROWYeah, or it's -- as I was talking about, this kind of common craving for knowledge. And so if that's not provided, you know, somehow, either through, yeah, other family members or some kind of historical guide or something, the role of these doulas and the home visitation programs for the moms through the pregnancy, so kind of this guide through the pregnancy. And then also once the child is born, then the home visitations and these early identification and early, you know, development aspects then become really important.

  • 11:54:44

    THUROWAnd that I saw in Chicago, and so there -- yeah, there might be some experts and then, you know, the kind of people that would hiring these privately, but the moms Jessica and Quintana that I'm following in Chicago on the South Side, they both had doulas from the Ounce of Prevention Fund Program, home visitation from there, also the Metropolitan Family Services. And these are -- these are community organizations and social organizations that have been around for quite a while.

  • 11:55:09

    THUROWYou know, they're -- they also have the funding issues, the political support issues that are budgetary support matters. But they're becoming more and more important, I think, and influential for that, particularly with, say, teen moms. And Jessica is a teen mom, she's in high school during her 1,000 days, and the lack of kind of services or education that's provided in the schools on a nutrition front or anything, these then community services become really important.

  • 11:55:37

    AUBREYGot it. Asma, around the world and developing countries sort of compare the services from experts compared to this, you know, woman-to-woman family support.

  • 11:55:49

    LATEEFI think it's going to take everything in -- and everything is context specific. And so as we think about U.S. development assistance and health assistance, it's really important that we are targeting what is -- needs to happen in a community and really understanding those needs in the community. And it will take layers of capacity. So you've got to invest both in the government capacity to create the policies and programs that will reach communities.

  • 11:56:21

    AUBREYThese things are going to be expensive to do, is that right?

  • 11:56:22

    LATEEFYes, you need to train people within the different layers of government, down to the district level. But then you also need to be training people in communities. You know, in Nepal there have been a lot of programs that have trained community workers on nutrition, and even after the earthquake, which was quite devastating in Nepal, nutrition outcomes didn't falter because these women were already trained, and they were -- they were going -- continued to do their work despite the tremendous conditions in their country.

  • 11:57:00

    AUBREYGot it. And Roger, with the last few moments we have in this show, after spending the last few years tracking these first 1,000 day movements, these women around the world, do you feel hopeful?

  • 11:57:10

    THUROWI do because particularly as 1,000 days movement grows, and there's some great leadership of that in Washington and then also around the world, this getting out nutrition movement, the things that Asma's involved with, but I think the realization of the cost of this that a stunted child anywhere in the world in a stunted child everywhere.

  • 11:57:28

    AUBREYWe are out of time. Thank you both for joining us. And to all of you out there listening, thank you for joining us. I'm Allison Aubrey of NPR News, sitting in for Diane Rehm.

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