Nairobi — A glossy nutrition pamphlet flies through the clinic's open doorway and hits a pacing rooster head-on. The disgruntled bird stops mid cockle-doodle-doo and struts away.
Alice Ngina Githae, the 71-year-old source of the projectile, chuckles to herself before turning back to business – treating the people of Mukuru who, unlike the rooster, are welcome inside. This sprawling slum on the eastern edge of Kenya's capital is a world apart from the glassy skyscrapers towering over traffic-clogged city streets. Mukuru's estimated 700,000 residents – no accurate count exists – have limited access to essential needs, including toilets, clean water and medical facilities.
Clinic staff struggle to provide what care they can – delivering an average of 30 babies a month, giving vaccinations, treating fevers and gastric disorders, providing HIV counseling. Now, a growing awareness of the far-reaching consequences of poor nutrition for mothers and their newborns could put the modest facility on the front lines of a national and global initiative to save millions of lives and boost economic growth.
Nearly 36 percent of Kenya's children are "stunted" – a condition as ugly as it sounds. If children lack necessary nutrients in the womb and through their first 1000 days, they are more likely to die as infants, and, if they survive, to have irreversible cognitive and physical damage, including reduced resistance to infection and diminished intellectual potential.
Conservative estimates put the cost to the Kenyan economy due to stunting at 128 billion Kenya Shillings (U.S.$1.5 billion) in one year alone. The Ministry of Public Health and Sanitation warns that "without deliberate and concerted effort, this figure will rise to three trillion shillings in 20 years ($35 billion) and 527,000 lives will be lost."
As high as Kenya's rate is, those of at least two dozen African countries are higher, according to a series on maternal and child undernutrition by the British medical journal The Lancet, with the percentage of stunted children ranging as high as 54.2 percent in drought-plagued Niger.
Researchers at the Institute of Development Studies (IDS) in the U.K. have been tracking the phenomenon of undernutrition, noting that while the number of stunted children has been declining across south Asia, in sub-Saharan Africa it has been steadily increasing. Because chronic nutrition is affected by many different factors, an IDS report said, it was "everyone's problem, but no one's responsibility – a classic failure of collective action."
Dr. Sandra Mutuma is the senior nutrition advisor to Action Against Hunger U.K. and lead author of a report on nutrition presented last month at Westminster, home of Britain's Parliament, by Action Against Hunger and IDS. She says only about 1 percent of the funds needed to effectively address undernutrition are currently being spent.
That may be changing, with both individual African governments and international donors showing new resolve to tackle the problem. Nutrition researchers have become advocates, arguing for relatively low-cost actions, such as breastfeeding counseling and vitamin and mineral supplementation for children under two.
Kenya has pledged to join the SUN Movement, a global coalition of 31 countries – 23 of them African – committed to an action plan called Scaling Up Nutrition. A high-level Nutrition Symposium next month will convene government officials, development specialists, private sector representatives and researchers to spur a nationwide campaign. The event will launch a food fortification drive, and a new law will require adding supplements to staple foods, such as maize (corn) flour and cooking oil.
For the SUN campaign to succeed, says Nicholas Nisbett, a nutrition fellow at IDS, a range of actions is required to create an enabling environment. "You need a political and policy environment which is conducive to action – the right resources to be dedicated towards tackling undernutrition and the political will and commitment from policy makers and bureaucrats all the way down to the ground level. You need the support of the media, and you need the support of the general public as well."
Alice Githae and her colleagues would like to be part of that effort at the ground level. But they're going to need more support than they're getting.
Before she opened the Alice Health Services clinic, Githae was a nurse and midwife at Pumwani, Kenya's largest maternity hospital, where 80 to 100 babies are born daily. After a long work shift, she would find women waiting at her house to get help, whether assistance with a delivery or evaluation of a sick child.
When she retired more than two decades ago, Githae became a full-time community caregiver, calling her new clinic 'Alice Health Services'. People already spoke of going 'to Alice' when they needed medical help, so it made sense, she says. She's not looking at a second retirement anytime soon. Being a nurse, she says, "made me able to bring up five children, and I also feel satisfied by assisting and advising other women."
She bustles nimbly around the clinic in a powder-blue lab coat moving furniture, counseling patients, doling out orders to staff and, in between, still acting as a midwife. "There are some mothers whose babies I delivered, and now the daughter is the one coming to me," she says.
Such informal clinics are increasingly important in densely settled areas across Kenya, where service provision lags far behind population growth. But Alice Health Services can't do it all. Complicated births and many emergencies must be referred to larger, better-equipped facilities, even though few clients can afford the fees.
Operating from a half-finished, barrack-style concrete block structure, Githae must make do with a shoestring budget from sporadic grants and modest patients' fees. But raising her rates is out of the question – the health center is the only option many area mothers can afford. Alice charges 30 shillings ($.35) for a clinic visit and 2500 shillings ($30) for childbirth services.
Two Catholic clinics in the area also provide health services but their offerings do not extend to childbirth. Although government facilities offer subsidized care to the poorest patients, the closest one is 3km away – a 600 shilling ($7) taxi ride. Pumwani charges 3000 shillings ($35) for a normal childbirth, 6000 ($70) if a Cesarean section is performed, plus 400-a-day ($4.75) room charges.
For many of those most vulnerable to undernutrition, small or informal facilities are the only sources of advice and aid. A week after giving birth, 19-year-old Bati Mutua, is back at Alice Health Services to have her week-old son Felix vaccinated. Hugging the blue-bundled baby tightly to her chest, she says softly that clinic staff showed her how to breastfeed him, an important precaution against poor nutrition and illness.
To encourage mothers to bring children under two for their recommended check-ups, Alice introduced these special Saturday clinics. The community responded.
Wooden benches outside the examination room are lined with young women clutching a baby with one hand and a health card with the other. One by one the mothers trickle in to have their children weighed, measured, pricked and prodded.
Gently laying three-month-old Benjamin on the government-provided measuring board, Elizabeth Mumo, 28, says the weekend clinics have made life easier. In a single visit she can get his shots, weight and height. When asked what she feeds him, she says only breast milk for six months "of course" – something the clinic taught her when her first child was born.
Nurse Lida Juma says follow-up visits can be critical to reversing the tide of underdeveloped children. If the child's growth is too slow, the parent takes home a sachet of vitamins.
The vitamin program began two months ago. Juma says health officials have so far provided only one box of 100 vitamin packets each month – not nearly enough for all the children who need them. Consequently, the nurses have cut back the dosages doled out.
"It has a negative effect, because you're not actually implementing what you're told to do, but we just don't have enough," Juma says matter-of-factly.
At one time, Alice offered nutritional counseling, including demonstrations on how to add vitamin and mineral-rich traditional vegetables to the maize-meal porridge that is the basic local diet, but grant funds dried up. Aside from a few posters of smiling families devouring plates of greens, the program has been reduced to dispensing advice during clinical sessions. She also wants to build a clinic kitchen and offer nutritional cooking classes.
"This is not an easy job," said David Nabarro, special representative of the UN Secretary General for Food Security and Nutrition at the launch of a Nutrition Barometer in New York last month. "It's incredibly difficult, and the people, the women, who are actually responsible for ensuring their children's nutrition are playing a very difficult lottery where the odds are stacked against them."
IDS's Nisbett is hoping to reduce those odds through Transform Nutrition - a consortium of international partners, including the University of Nairobi. Kenya and Ethiopia are two of four pilot countries – along with India and Bangladesh – where research-based evidence will be used to inspire effective action.
Because the challenge is multi-faceted, so is the initiative. It aims to help direct interventions, such as improving the nutritional status of pregnant mothers and newborns, to scale up more rapidly and to be more effective at a national level. It will also explore wider issues, such as how to support the families of small farmers, who grow their own food but are among those most at risk for nutritional deficiencies.
Alice Githae is looking for more immediate assistance. "Can you get me a car?" she asks two visiting reporters, so that maternity patients needing urgent care no longer need to be transported by wheelbarrow.
This story was produced in collaboration with the Institute of Development Studies.