 And now for something completely different, because childhood under nutrition leads to a lifetime of negative consequences. It's often used as an indicator of poverty or household welfare. What I propose to do today is to look at a particular indicator, which I think is important because it's under discussion for inclusion in the next round of MDG goals. So let me go. Whoops. Ah, okay. What got me started on this was I was looking at in Zimbabwe in the early 80s the effects on household welfare of redistributing land to near landless households. I've got what I think I haven't been contradicted yet is the longest panel study in Africa of a group of land reform beneficiaries and non-beneficiaries, four to 600 households a year across three different agroecological zones. And I've used a broad mix of both conventional indicators and non-money metric ones, principally indicated related to health and nutrition. To cut to the chase, what I found over time is I've looked in more and more detail at these is a paradox. There's an average decline in nutritional welfare of 1.4 percent a year over two decades. No matter what happens with rainfall, with income, what have you. This same trend is indicated by the first acronym is Zimbabwe Rural Household Dynamics Study and the second is Zimbabwe Demographic and Health Surveys. So the panel study, you look at the two trend lines, a panel study pretty closely matches what's indicated by a large scale random national survey done at periodic intervals. So the probability of a household being undernourished at the end of two decades is 25 percent higher than at the beginning. I was very puzzled by this, which led me to play around with some development economic concepts. One was to look at these outcomes on a household basis and I considered the nutritional status of both adults and children and this takes over a five year period just for illustration. A household is symptomatic if under nutrition exists and this is below two standard deviations for children and below a body mass index of 18.5 for adults. So what you have here is an indication 16 plus percent of households have under nutrition both among adults and children. As a development economist you may think, okay, that's clearly perhaps a poor group, a group that needs attention. On the other hand, you've got almost a third of households have no symptoms of under nutrition. You might think, okay, this group of households is pretty well off, we don't have to worry too much about poverty. What is interesting though is the difference in these verticals. You've got 63 percent of children are undernourished and 21 percent of adults. So there are things going on here that looking at things from a household perspective can seal perhaps more than they reveal. So the nutritional assessments I suggest aren't particularly helpful. One reason is if you've got 60 percent of children who are undernourished, that is the norm. So the other welfare indicators you might look at don't tell you very much when you've got that norm. I've referred already to the contradictory outcomes. Income, food production, food purchases, none of these fits very well with patterns of under nutrition. Part of this may relate to the approach I've taken in this particular analysis is looking at simply a presence or absence of under nutrition using dummies. It may be, and with the thresholds, it may be that it's a depth of deprivation that's more important than the presence or absence. And I can't answer that question at the moment. And then finally, it doesn't work at a household level because the cause and effect relationships for under nutrition among adults and children are very different. Adults typically should add data, always collected in what's considered the hunger season. This is the period of acute agricultural activity and declining food supplies. So it should be pretty good at detecting nutritional stress. This I think is a critically important one. I'd particularly like to draw your attention to what's going on here. This is based on over 7,000 observations. Chronic under nutrition, the blue line, height for age, and acute under nutrition, the red line, weight for age. What's interesting about this is the periodicity, two recent sets of articles in the Lancet, and I've read over, I'm changing professions, I think I've read over 100 medical papers to do this, suggests that the critical period for child growth is the first 1,000 days of life from conception to the second birthday. That's when it really all happens. So we're talking about, you've got nine months back this way, and then you've got down to this period. What is very striking is that all of these children are born to spend the first few months of their lives above the values that you would expect, above that zero. But at the age of about six months there's a precipitous decline. Four things are going on here. One is it begins to be, it's the age when children begin to be fed solid foods. So they're not exclusively breastfed. The other thing that begins to happen, and I'll elaborate this on a moment, is it's the age when mothers begin to put their children on the floor, and children explore their worlds by putting pieces of it in their mouths. I'll come back to that as I said. So that's why that age is critical. Now what's going on here is something that development economists have missed in the medical profession. It has known about for 50 years, but didn't appreciate the significance of. This is a phenomenon known as environmental interopathy, formerly known as tropical interopathy. And it's universal among people living in unhygienic conditions. Now bear in mind my households are entirely rural households. You do not find this condition to anywhere near the extent among urban households. So it's a pretty much a rural phenomenon. The etiology is unclear. Doctors think it's due to, as I said, unhygienic conditions, often simplified to fecal oral contamination. No hand washing, no toilets. But then it's also been implicated to dirty water supplies. It's also associated with living in very close proximity to animals. It occurs among pastoralists, periodic wanderers and residential households as well. So it is pretty universal. And it underlies the death of half of under, well, half of under five deaths. Okay. Now for a type of graphic that you seldom see in a wider conference, if ever, just to give you some idea of the mechanism involved, the human digestive tract is about nine meters long in adults. Six to seven meters of this length is a small intestine. That's where the real work is done. The stomach absorbs some sugar, the large intestine absorbs some protein. But the real work of absorption is done in the small intestine. Now on the interior of the small intestine, a closer view, you have these little finger-like projections called villi. And you can see at this level of magnification. Even more closely, you've got healthy villi looking like this, these grape folds with the finger-like projections. The importance of these things is that the absorptive area in the human gut, a healthy human gut, is ten times, more than ten times the area of human skin. It's a huge area. Two things are going on here. These villi absorb nutrients into the bloodstream. The base here, you have a set of glands. These are basically glands that feed enzymes back into the gut and assist in digestion. There's another factor that's important, and that is this membrane. The gut normally is not easily soluble and it's filled with toxins. Now these are healthy. Let's go to a different perspective. Here you've got the same healthy villi here. You've got two parts of the crypt at the base and the villi themselves. The ratio is normally in a healthy body, it's two to one. These are villi affected by environmental interopathy. What's happening is you have excessive production of cells. The cells coat the villi and reduce the absorptive capacity. The other thing that's going on that you can't see is that the glands that assist in digestion can't get their juices into the gut. There's a third point that's going on here is that this barrier becomes permeable. So toxins are leaking from the gut into the bloodstream. In the terms that medical anthropologists use, environmental interopathy is an invisible disease. But the medical anthropologists usually refer to invisible diseases as diseases in which I know I'm suffering from something but I can't persuade anyone else, my parents or my doctor to believe that I'm suffering. EE is invisible in every dimension. The sufferer does not know that he or she has any condition. The carers do not know that those they care for have a medical condition because with stunting under nutrition as the norm, my children look the same as everybody else's children. So we don't see a difference. There's no, not easy to detect. The medical profession cannot diagnose environmental interopathy. And they don't know who's suffering. And then worse, the effects of environmental interopathy are largely irreversible. There is, there may be a modest catch up effect, but it's not significant. I'll come back to that in a moment. Now if it's subclinical, which it is, how do you then spot it? Well medical researchers use the most common goal standard test is what's called the LM test, which is to administer two different sugars to someone who's suffering from EE. And the sugars, one sugar leaks out into the bloodstream and the other goes into, may or may not go into the large intestine. But it's the ratio of these two sugars that determines whether you've got it or not. So essentially you create, EE creates addition where malabsorption of nutrients reduces the resources during critical periods of growth. I should go back to that, the diagram, if you remember the retardation of growth. Something that's really not appreciated terribly well. I've done work with Harold Alderman at the World Bank and John Hudnock at IFPRI looking at the outcomes of poor nutrition, particularly on educational performance. You get late entry into school, you get poor performance in school, you get fewer years of schooling completed and so on and so on and so on. What we hadn't linked it to earlier is the fact that in the first thousand days of life, all the brain cells you will have in your life are created. As you grow older, neural networks become more operative and change become more complex. But you have your basic supply of brain cells by your second birthday. And after that there's no, you're not creating any more. So that is in part what underlies this poor educational and economic performance for the rest of your life. You have a, you face a severe, severe handicap. This leakiness in the gut causes an immune system response. Remember these are toxins. So your body mounts an immune system response which in the young child uses more of these precious growth resources. So you have the obvious physical stunting and the less obvious mental stunting. Just to show you what this growth curve look like, the blue, the red is this Gambian data. The red is weight gain, not height gain. And the blue is the lactose-manutol ratio. So it's a mirror image as that sugar leakage test goes down, then growth goes up. Okay, how do we tackle this in an attempt to create greater inclusivity in growth? Well, typically different professions have approached the problem from their own narrow perspectives. Two programs, for example, I reviewed 42 different feeding programs attempting to deal with this. You have an average growth deficit among African and Asian children of minus two standard deviations. The best feeding programs achieve about one-third recovery from that growth deficit. So there's some catch up, but it's far from complete. The medics have tended to approach it from a disease-controlled perspective and particularly have focused on diarrhea as the leading cause of child death. But the interventions that have tackled diarrhea produce no change in linear growth in children. They do reduce mortality rates, but they don't change the growth outcomes. Water sanitation and hygiene interventions, even with almost universal coverage, reduced diarrhea by 30 percent, but under nutrition only by less than 3 percent. Combined water sanitation and hygiene interventions give you approximately the same degree of improvement as dietary interventions. So the medical literature has, using diarrhea as a principal cause, has tended to underestimate the contribution of hygiene to the problem. Then I just summarized some of the Gambian data, which is where the best combination of medical research and social science research has been done. And again, solving the diarrhea problem does not solve the under nutrition problem. There is, I suggest, no easy way out of this. What is required is one of the most difficult things in development work, and that is profound behavioral changes. One is basic household level hygiene practices, such as hand washing, the availability of soap. Child rearing behavior is another one. If you ask me what might work best for children or mothers in Africa, it would be play pins. Just play pins isolate the child from the environment and let the mother get on with what she has to do without endangering the child's health. But there's a whole set of issues around child rearing behavior and maternal time management. One of the things that's quite striking in my panel is that because these households were given additional land, it was created at the same time an additional demand for agricultural labor. So women's labor and field work became much more valuable, and they were taken away from domestic responsibilities. Infants were left in the care of siblings and weren't particularly well looked after. High density wing foods can be critical in that first two years of life. There's not a lot of evidence so far that points in that direction. Life water supplies, domestic toilets, and livestock management practices. The livestock management basically means you keep your chickens and goats out of the domestic living area and put them someplace else. So what I find is a long term secular change in decline in nutritional status in Zimbabwe. The norm as a household with well-nourished adults and undernourished children, at least one undernourished child. I pointed out the paper goes into much more detail about the association between nutritional status and a whole set of economic indicators, which I worked on for a long time with very frustrating outcomes. Something I'm just beginning to look at is the distribution of nutritional outcomes because I suspect that they are not randomly distributed, that there are other things going on. And I can't, despite looking, first couple of rounds of looking at association between nutritional outcomes and factors that predispose to environmental interopathy, I haven't got very far with it. And then finally on back to the theme of the conference, a child who experiences environmental interopathy in the first two years of its life cannot benefit from inclusive growth. But by definition, there is no catch up and inclusive growth is not going to benefit these children. And I leave with a set of questions. The most important of which I think is perhaps the third one. And that is the perspective on different people working in development on issues such as food security. I mean, the basic, the bottom line here is we are not what we eat. A nutritionally adequate diet does not lead to satisfactory growth of young children in these conditions. So increasing agricultural productivity, food aid, a whole set of common interventions are not really going to help with this particular problem. And at that point, I will leave it, sorry to be so gloomy.