Sierra Leone is currently grabbing headlines due to the world’s worst outbreak of Ebola to date. But those working on health in this small West African country have pointed to the many other diseases and conditions that kill people on a much more regular basis. These include malaria, TB and – perhaps the largest killer – malnutrition.
Sierra Leone is home to one of the world’s most malnourished populations. It is a country where, every year, malnutrition claims more than half of the deaths of all children under 5; where a child’s chances of regularly attending school and getting a decent job later in life are seriously threatened by this awful condition. And it affects far more people than does Ebola. To put things into perspective, the current number of laboratory-confirmed Ebola cases in Sierra Leone (at the time of writing) stands at just over 1,000; in 2010, a nationwide survey found that 44 percent of all children under the age of 5 were stunted, or too short for their age as a result of malnutrition. (This is of course not to downplay the fact that Ebola has a far higher mortality rate on a case-by-case basis).
Governments and aid agencies often attempt to prevent malnutrition by investing in the promotion of good infant and young child feeding practices (early initiation of breastfeeding, exclusive breastfeeding, and so on). That is clearly sensible. But the realities of knowledge transfer and behavior change – getting someone to do something differently – are always much more messy than we often like to think.
Two recently published news pieces highlight exactly why preventing malnutrition in developing countries is so difficult and so complicated. On the one hand, efforts to stop kids from becoming malnourished tend to focus on diet rather than environment, which is really problematic given what we know about the close interactions between sanitation and nutritional status. On the other hand, social norms often create enormous stumbling blocks for health and nutrition policies; the widespread preference for firstborn sons in India, for example, diverts food, capital and care away from other children in the family.
But there is still one important piece missing from this picture: seasons.
In June, as part of a two-year study into state capacity and malnutrition, colleagues and I spent some time in northern Sierra Leone interviewing communities about what we might call the social causes of malnutrition – the kinds of behaviors that limit a family’s ability to provide care for their children. We found that while the risk of a child becoming malnourished may be perennial, it appears to spike during certain periods of the year. This phenomenon is not specific to Sierra Leone. In fact, we see it happen across the world. The following graph, taken from a report by the international NGO Action Contre la Faim (ACF), shows how the number of kids admitted to one particular therapeutic feeding center in Guatemala consistently explodes between June and September, year after year.
Why is this the case? For Sierra Leone at least, our research found that in rural areas dominated by farm-based livelihood activities, a series of dynamics associated with the rainy season combine to produce a “perfect storm” of conditions for the emergence of malnutrition. Here are three (and you can read a little more about them in this briefing paper we just published).
First, there are low levels of food access and limited coping strategies available to most families.
Sierra Leone’s rainy season runs from roughly May to September – for about a third of the year. By the time the rains arrive, many households are running low on food: the previous year’s harvest is drying up, and there are still some months to wait before the next crop will be ready (it’s not called the “lean season” for no reason).
Most households seem to deal with this either by taking loans (in food or cash) from creditors, or by adapting feeding practices (eating smaller meals with less protein, eating less frequently). Creditors are known for charging sky-high interest rates (100 percent is not uncommon), which means that while they provide a short-term fix, they can create longer-term dependencies that do little to help people break the cycle of hunger and poverty. And typically, it is the mother and her children who are at the sharp end of coping strategies vis-à-vis food allocation, as they eat the smallest portions with the lowest quality ingredients after men and elders.
It is also worth mentioning that the current border and road closures in West Africa – implemented as part of efforts to contain the Ebola outbreak – are probably making it even harder for poor households to access food and credit right now. Indeed, one paramount chief (these are important local leaders in the Sierra Leonean governance structure) was recently quoted in the New York Times as saying, ‘Our fear now is that closing these roads risks having more people die of malnutrition and even starvation than by Ebola’.
Second, environmental hygiene is worse during the rainy season.
Long-drop latrines are often absent from many communities in rural Sierra Leone, meaning that people may have little option but to openly defecate in bushes or rivers. This creates a particular problem in the rainy season when excess soil saturation leads to high levels of surface runoff, thus increasing human exposure to contaminated water sources. This, in turn, heightens the risk of diarrhea and other forms of infection and disease, which are linked to higher incidences of malnutrition.
Third, labor demands increase.
Farmers in Sierra Leone usually consider the rainy season to be the most difficult time of year, because of how hard they are required to work during this time. These months are when cultivation demands are highest, and people’s days are spent in the fields performing a range of tasks, including threshing, ploughing, transplanting and harvesting (although both the necessity and timing of these will vary by crop).
The pressure to expand the agricultural labor force at this time means that many women are expected to cultivate land and harvest crops alongside men. But a woman who has been on the farm all day is still expected to prepare food in the evening, as well as take care of the ‘standard’ domestic responsibilities. As the chief of one village told us, “Pregnant women are suffering in this community. They have to go to the farm, cook and look after the family. This causes problems.” For lactating mothers, the additional responsibilities during the lean season are particularly challenging. Participation in agricultural labor can keep women away from the home for hours on end. Given that exclusive breastfeeding is essentially a full-time job, this poses enormous risks to healthy child development.
We have known about the impacts of the seasons on health and agriculture for decades. It therefore seems remarkable that this fundamental issue still does not feature as a core pillar of health and nutrition programming. Sierra Leone’s new National Food and Nutrition Security Policy is a perfect example: while great in many respects, there is barely any mention of seasonality beyond its implications for food access.
But seasonality is not just about having less food. The rains interact with other factors we know to be important in driving malnutrition, such as environmental hygiene and deeply unequal gender relations. This ‘perfect storm’ may only come round once a year, but it is deadly. Failing to recognize this is failing to come up with viable year-round solutions to one of the world’s largest yet most invisible killers.