Stunting or chronic malnutrition is the most common paediatric growth disorder in the world [1]. Stunting in early childhood is closely associated with developmental delays, poor school performance and, ultimately, decreased adult economic productivity [2]. Although stunting doesn't necessarily directly mediate developmental delay in all cases, it is still a very useful proxy for the numerous social and structural risk factors that impact poor and marginalised children worldwide.
Since completing my medical training, I have focused my efforts on the social determinants of child and community health in rural agrarian settings around the globe. I have spent most of my time on work with Wuqu' Kawoq | Maya Health Alliance in Guatemala. This is a primary care and research organisation which does exciting work with indigenous Maya communities to understand determinants and improve health outcomes for children. Guatemala is an important place for thinking about paediatric nutrition, since it has one of the highest rates of stunting in the entire world, disproportionately so in the rural Maya communities where we work [3].
Over the 15 years I have been involved, we have made tremendous progress on multiple fronts. For example, when I first began this work, health professionals and policy makers almost universally and wrongly thought that stunting was genetic. However, the science has shown that stunting is mostly caused by adversity and poor health and not by genes [1]. Sustained advocacy work has completely reversed the misperception, and this has caused a tidal shift in Guatemalan politics, with child nutrition now front-and-centre on the policy agenda. There has been a ground-swell of interest by private sector partners, which has brought new resources and alliances. Citizen's groups and the press are vigilant, keeping tracking of progress and pressuring politicians and public health professionals for accountability. This is all tremendously encouraging.
There remain many challenges. Funding for child health remains fragile and sporadic, and most efforts to address stunting have had limited impact. This is partly because of a continued short-sighted focus on technical nutritional interventions (micronutrients, supplementary foods, and so on). What is also needed are broad-based social initiatives to empower rural indigenous communities and caregivers, and to reverse poverty, economic inequality and discrimination.
As we train the next generation of paediatricians, nutritionists, and therapists it is also important that we nurture our ability to keep each individual child and family in view. It is tempting to think of big problems like stunting only in aggregate, as national or global issues to be addressed incrementally. But the enteropathy, growth faltering, and developmental challenges that the child you see today in your clinic is a very real and urgent suffering. That child's caregivers may have few resources at their disposal and perhaps little hope that things can get better. We must train the next generation of clinicians to navigate this space, to creatively solve problems together with children and their caregivers, to celebrate small clinical advances, and to rejoice in the collaborations we forge with families.
Contributors
P.R. conceived and wrote the manuscript.
Declaration of Competing Interest
No conflicts of interest to declare.
Acknowledgments
I would like to thank all of my colleagues at Wuqu' Kawoq | Maya Health Alliance who continue to inspire this work.
References
- 1.World Health Organization. Child growth standards. Available at: https://www.who.int/toolkits/child-growth-standards.
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