And just like that, we are living in 2018. And what better way to kick start the new year then talking about the future – our children.
Not too long ago, business daily The Edge published a special report with a screamer: that the incidence of childhood stunting is the highest in Putrajaya.
The report was based on a preliminary finding of a survey jointly conducted by the Health Ministry and Unicef Malaysia. The National Health and Morbidity Survey (NHMS) 2016 found that 28% of children aged 12 to 23 months in Putrajaya suffered from stunting.
Now, who would have thought that the administrative capital of the country had the highest number of stunted children? Actually, why should a nation – such as Malaysia – on the cusp of breaking into the high-income club even have malnourished youngsters?
It seems the answers are not straightforward.
The lack of a benchmark
Simply, a stunted child is one who is too short for his or her age. This condition is believed to be a largely irreversible outcome of inadequate nutrition and repeated bouts of infection during the first 1,000 days of a child’s life.
And there are a host of problems that contribute to stunting, from bad feeding practices to the poor health and nutrition on the part of the mother.
A common benchmark is the World Health Organisation (WHO) Child Growth Standards set in 2006 – one which the NHMS reports also rely on to determine the percentage of stunting in Malaysia.
These reports can be downloaded from the Public Health Institute’s official website, and they cover a wide range of issues from healthcare demands to non-communicable diseases. The site is replete with a backgrounder and FAQs, too.
Now, the latest data on stunting is found in the National Health and Morbidity Survey 2016: Maternal and Child Health. It’s this report that we’ll refer to when we talk about stunting or whenever we refer to the abbreviations NHMS 2016 or NHMS. And as for children, we are referring to those below the age of five.
(The preliminary findings, which The Edge cited earlier, is not found in the National Health and Morbidity Survey 2016: Maternal and Child Health, nor is it available for download on the Unicef website.)
So according to the NHMS, the national prevalence of stunting is 20.7%, three percentage points more than 2015.
But the problem is, “Malaysia does not have its own growth chart,” says Dr Muhamad Yazid Jalaludin, a consultant paediatrician and paediatric endocrinologist at the University Malaya Medical Centre (UMMC).
“Even other Asean nations such as Thailand and Indonesia have their own growth chart. Singapore too. But we don’t and that makes it very difficult for us because you are comparing yourself to a global standard.”
This bit has been glossed over by much of what’s published out there on the problem of stunting, including The Edge report: Malaysia does not have a national benchmark.
Of course some kind of standard is better than none and in the case of the NHMS, it uses the WHO standard. If we were to take that as the benchmark, and remember this is a 2006 one, then Malaysia has a problem, because based on that, we should only have around 3% stunted children.
“So there’s definitely an issue there. What that is we have to look back at the number of children the report studied. And we really need to review how we feed our children, especially complimentary feeding.
“We have been pushing for our babies to be breastfed and we are seeing a better percentage of those less than six months growing well. But once they are supposed to be fed solids, they don’t grow as well and that boils down to how our parents understand nutrition and complimentary food.”
Yazid’s observations coincides with the NHMS findings on stunting where the most affected group are children within the 12-35 age band.
When it comes to growth factors of a child, what’s generally accepted is that the first two years of life is determined mainly by nutrition. Between three to five years, other variables besides adequate nutrition come into the picture such as genes, parents’ height and growth hormones.
Another important variable that Yazid raised is the rise of picky eaters. A novel programme called the Malaysian Identification and Management of Feeding Difficulties (IMFeD) is set up to do just that: enable paediatricians to accurately diagnose feeding difficulties in children, which Yazid is also part of.
Putrajaya: the land of unhealthy civil servants?
Now, according to the NHMS 2016, Putrajaya ranks fourth – after Kelantan, Terengganu and Pahang, respectively – when it comes the number of stunted children by state at 24.3%.
This confirms the findings of the preliminary reported cited by The Edge earlier that the administrative capital has a problem with stunting.
Yazid of UMMC said according to some studies done among older children living in Putrajaya, the does rank high for stunting and obesity.
“But is it also because they are generally short? When you are short, your BMI will increase. But these can also fall into the problem of malnutrition, especially when you are given problematic food either too much or too little of it.
“This is just me speculating but it is a problem because is this short just being short or short due to some health issue?”
Aside from the doctor’s notes, what has been published about Putrajaya is unpleasant. Yazid pointed out obesity among older children, but overall the administrative capital has the highest percentage of overweight, obese and abdominally obese people in the country.
As it is a city of civil servants, “they have no choice but to live in this location despite the fact that they may be unable to cope with the cost of living there,” says Azrul Mohd Khalib, founder of Galen Centre for Health and Social Policy.
He attributes the prevalence of stunting due to serious malnutrition, citing poor diet choices that are dictated by rising food prices.
“Poor diet choices (e.g. high-calorie foods) are currently being made by many Malaysians simply because eating healthy is becoming increasingly costly due to rising food prices.
“Most civil servants affected are from low-level-income households which are struggling with this issue. What happens is that lower income households spend most of their money on food. Unfortunately, it will be cheap processed foods such as fast food and instant noodles which are attractive options for less money.”
Azrul’s observations hits home a discussion that rarely gets raised on both sides of the political divide: the salaries and allowances of civil servants especially those on the lower end of the pay scale.
Currently, employees on the lowest grade, combined with existing allowances, bring home a take-home pay of RM1,500.
This led the the Congress of Union of Employees in the Public and Civil Services (Cuepacs) to ask for double salary increments to all civil servants regardless of their employment groups and ranks. Their request was not entertained during the tabling of Budget 2018.
Other reports also paint a negative picture of the state of civil servants. This is the very group that have taken on more debt either due to low pay or financial illiteracy. The Insolvency Department says the number of bankruptcy among the civil service is rising every year.
Just after The Edge report on stunting was published, The Malaysian Insight talked to ten families and discovered that six of them cited late nights at the office and a lack of knowledge on nutrition among the reasons their children’s diets were neglected.
These parents depended on their nurseries and kindergartens to feed their kids as they did not have time to make packed meals.
We tried contacting a representative from Putrajaya Hospital to get some responses on stunting and malnutrition but our request was declined.
A microcosm of the Malaysian workforce
And maybe this is symptomatic of the Malaysian labour force in general. Consider some of the recent statistics coming out about the state of work in the country.
Malaysians are working longer than their contracted hours each week, even surpassing the likes of Singapore, Hong Kong and Australia. Our productivity is also a taking a hit.
Not only that, the country has the highest percentage of employees who slept less than seven hours a night. And a worrying 15% of Malaysians are skipping meals to make ends meet.
A sedentary lifestyle, horrible sleeping patterns and stress are a killer combo for obesity and other non-communicable diseases such as diabetes, stroke and heart attacks. Ironically, we are known both for our expanding economy as well as waistlines, and we are champions when it comes to the latter. Not something we should be proud of.
“And this also questions what the government considers poverty. In a country where absolute poverty is 0.4% but stunting is 20%? This is the problem when you put the poverty line relatively low. RM950 is a ridiculous figure,” says Dr Michael Jeyakumar Devaraj, who is Sungai Siput MP and a central committee member of Parti Sosialis Malaysia (PSM).
Malaysia’s poverty threshold is RM950 or below and RM600 for the hardcore poor. Jeyakumar has been calling for a revision, urging the government to follow in the footsteps of the UK and other developed nations who based their poverty threshold on 60% of median household income.
According to the Household Income and Basic Amenities Survey 2016, the median household income is RM5,228, so according to the 60% rule, the poverty line would be adjusted to RM3,136.80. Meaning houses who fall below this line are considered poor and it seems to make more sense as opposed to the current metric.
“Even in Sungai Siput, RM950 is not enough. Rent itself is around RM300, then how much do you have for food, transportation, school? It’s a problem,” says Jeyakumar.
One way to deal with this is to raise the minimum wage which is due for revision this year. “But Malaysia is part of the global economy. So if for example, we want to raise minimum wage to RM1,800, there is a real danger some businesses will shift production away from Malaysia. This will lead to job loss and, ultimately, loss of income,” quips Jeyakumar.
Azrul also admits that the problem is a complex one and “the only real, long-term and sustainable way to address this issue is to ensure that people are able to get better paying jobs. This is dependent on many factors which require a better business and economic climate.”
Cash transfers with a twist
So where do we start? If you take a look at the health ministry’s “Nutrition Programme” page, it's obvious we have the safety nets and mechanisms in place to deal with malnutrition in general.
One country that has been a trailblazer with respect to improving child nutrition is Brazil and among its set of policy initiatives, a standout is its conditional cash transfer.
Dubbed Bolsa Familia, it is the world’s largest conditional cash transfer programme. Its purpose is to combat hunger and provide nutrition security, among others. Families in poverty or extreme poverty are entitled to this especially those with families composed of children from zero to 17 years of age and those with pregnant or lactating women.
And once a family enrols, it must comply with certain health and education conditions to remain in the programme such a minimum school attendance for children seven to 17 years old.
There’s also a health and nutrition agenda for beneficiary families with pregnant women, nursing mothers or children under seven years of age (pre-natal care, vaccination, health and nutrition surveillance).
But here’s the kicker: In most cases the cash transfer is paid to the reference female of the family group.
And believe it or not there is evidence that shows women are able to make greater productive investments than men. Such conditions if they were to be executed also allows the cash transfers to reach its intended demography: poor children. Not the pockets of the parents.
Now, Malaysia has BR1M for a cash-transfer programme, but the quantum is too little and the application process is too simplistic and easily abused.
The World Bank for example has praised the initiative as it did increase spending. But the problem is it's a blanket policy, where even a rich retiree can claim some amount, designed as a stimulus. Not forgetting, populist. But that has to go and be replaced with something more effective.
Also why the idea of conditional cash transfers is effective, especially if it's given to the mothers, is simply because of the correlation between stunting and household economic conditions. According to the NHMS, more stunted children are found where:
- the marital status of the mother is divorced/separated/widowed/never married
- the mother either did not go to school or had education up to primary-level
- the mother is unemployed or worked in the public sector. Interestingly housewives fair better than these two groups
- a household earns less than RM1,000
Another policy move that needs to be implemented together with cash transfers is to make regular paediatrician visits compulsory and to make it a requirement for children to have medical records before entering school.
“Usually after you complete the immunisation cycle, you should drop by a hospital or a government clinic, say, one every six to 12 months for a regular check-up. But there’s not many takers. Parents don’t it,” observes Yazid.
“In fact we should monitor their growth until they are 18.”
The need for effective policymaking
If anything, this is what all the ambiguities and findings we have surrounding data on stunting point to. Which is also the problem.
Recently the health ministry released a set of policies to lower the rates of non-communicable diseases. Among them: to shorten the operating hours of mamak stalls and also impose a sugar tax. Even Unicef, as quoted in The Edge article, also called for a tax on sweetened beverages to encourage people to choose healthier drinks.
But these manoeuvres are immature. Is there any evidence that raising sugar prices will lead to less sugar consumption? In the case of malnourished children, will forcing mamak stalls to close at certain times or even making sugary drinks more expensive ensure that parents will be wiser with their food choices?
If anything, the ambiguities and information on stunting point to a very huge elephant in the room: inequality.
And we have to promptly deal with this as our children's future gains depends on decisive actions. Actually, make that our country's future gains.
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