How do you tackle widespread malnutrition in a poor, corrupt country at war?
Despite billions of dollars in aid over the last decade, Afghanistan’s malnutrition rates have soared, now well-past emergency thresholds, with one-fifth of children malnourished overall; one-third of children acutely malnourished in some conflict areas; and 60 percent of children under five stunted, according to a recent survey by the government’s Central Statistics Organization and the UN Children’s Fund (UNICEF).
“You have malnutrition rates which are among the highest in Asia and equivalent to rates deemed totally unacceptable in other parts of the world,” UN humanitarian coordinator in Afghanistan Michael Keating said in a recent interview, adding that he was “shocked” by the results of the survey.
The UN Office for the Coordination of Humanitarian Affairs (OCHA) admits humanitarian organizations have had “major gaps” in their capacity to respond to the nutrition crisis, with past attempts to establish a UN “cluster” focused on nutrition failing due to insecurity.
But a new four-year US$6.4 million project run by the World Food Programme (WFP) and the Global Alliance for Improved Nutrition (GAIN) aims to reach nearly half the country's population - 15 million Afghans - with fortified foods.
The strategy is to add vitamins and minerals such as iron, zinc, folic acid, Vitamin B-12 and Vitamin A to wheat flour, vegetable oil and ghee, and also fortify salt with iodine.
While large-scale food fortification has succeeded in curbing malnutrition in places like South Africa and Egypt, can it work in Afghanistan? (Food fortification is not new in Afghanistan, but has only been done on a small-scale).
"There are several problems, besides security which is an obvious issue," said one Afghan analyst who asked to remain anonymous. "Are Afghans prepared to eat this food? How are you going to convince people that something added to their food is good for them? Afghanistan is full of conspiracy theories. And then there is corruption; how can this be implemented so those who buy the fortified wheat flour are not taking it out of the bag and filling it with other flour? In a large project like this, mullahs [religious leaders] and tribal elders need to be key advocates, otherwise it won't work. And getting Afghanistan's neighbours to comply and work for the good of Afghanistan is another story."
At a time when aid budgets are shrinking as foreign troops withdraw from Afghanistan, observers say the project will have to follow certain key steps to avoid becoming another example of wasted aid money.
When fortified bread was introduced in Egypt, the project targeted state bakeries that make subsidized bread for the poor. By contrast, Afghanistan's fortification project will be market-based, which is why, project organizers said, the marketing strategy will be a key component of its success.
While women are responsible for most of the feeding, men do most of the shopping, said Emily Levitt Ruppert, the senior policy adviser for maternal and child nutrition at the Nutrition Centre of Expertise at World Vision International.
Education is a strong social value, as is having healthy, intelligent children, she said, and the word "vitamin" is generally understood. One strategy is to convince men that to have smart, healthy, athletic children, they should give their families fortified flour, which will also help prevent birth defects.
Ibrahim Parvanta, an international nutrition consultant, helped start the country’s first salt iodination programme in 2002, after the fall of the Taliban. In his experience, getting Afghans on board was not difficult. Both salt iodination and so-called sprinkles, a micronutrient powder that allows people to fortify their own foods at home, “were incredibly accepted", he told IRIN.
The key, he said, was talking to Afghans' hearts, as well as their pockets. “You want your children to be successful in school?” he would ask them. “Well then this is what we need to put in it [food].”
According to Purnima Menon, a senior research fellow at International Policy Food Research Institute (IFPRI) in New Delhi, fortification can be quite sustainable, but a demand for fortified commodities is essential.
Given the current economic conditions in Afghanistan, success is tricky. "Besides the other competing products in the market, it also depends on what the people buying it think." Any change in the food’s appearance or taste could sway consumers against it.
While a small percentage of Afghans living in rural areas have plots for growing their own wheat, and WFP distributes food in some areas, the main food and cereal supply is through free market mechanisms - mostly imports from neighbouring countries.
"Afghans will see labels that the products are fortified, so that will help,” said Marc Van Ameringen, the executive director of GAIN, “but how to build effective demand is one of the challenges we face around the world. In many countries, this works by government regulation, which is also the plan here. But the thing in Afghanistan, as in a lot of other places, is: Can you enforce it?"
Once there is demand, how do you market your product?
While one third of the population lives below the poverty line; as in other countries, loudspeakers are still used to spread news. Roughly 80 percent of the population has access to a cell phone, and advertisers are increasingly using SMS messages to reach people. Billboards have also mushroomed in the past decade. However, with an 80 percent illiteracy rate, these types of marketing are not as effective, said Rafiq Kakar, president and CEO of Opinion Research Centre of Afghanistan (ORCA).
Radio is a better option, he said, though he cautioned that Afghans can be skeptical of radio advertisements.
"We have found people have the most confidence in tribal elders or religious leaders. They believe whatever elders tell them - even if it has to do with something they don't like very much."
WFP says in previous marketing campaigns, they have not only relied on radio, but also involved doctors, clinics, leaflets, posters, pamphlets, even danglers.
What is needed, the consultant Parvanta added, is a tracking system - to market the fortified products in the right places, monitor exactly where they end up and to see the impact of the foods on the population. Wheat flour importers and national producers could help advise on this process, he said.
The project is more likely to succeed in urban centres than in rural areas, he said, but with 13 national mills participating in the project, “you would still reach a good 25-35 percent of the population, which is a substantial number."
Reach in remote or conflict areas will necessarily be limited, aid workers concede.
“The challenge is making sure that they are targeted towards the areas where you have the highest need,” said Aidan O’Leary, head of OCHA in Afghanistan. “The areas most affected are invariably the most conflict-affected areas.”
Getting government to take ownership
Ultimately, WFP representatives said, the goal is for the government to take ownership of the project.
"Basically," said Doordje Voovic, of WFP's Purchase for Progress initiative, which purchases food from local farmers, "this project has to do with the whole system of supply of a country. While we are at the very beginning of the chain, the net result is out of our hands.”
Given the weak central government and high levels of corruption, the government's capacity to implement such projects is often very limited, observers say. This is why the project requires properly trained Afghans who can absorb and implement the projects and then continue to run them properly, said Parvanta.
"One of the biggest problems is that there has not been enough resourcing to develop Afghans with proper skills to [implement projects],” he said.
Save the Children and World Vision’s recently released Nutrition Barometer, which measures national responses to malnutrition, found the political commitment for tackling malnutrition to be emerging in Afghanistan through the National Public Nutrition Policy and Strategy and the Infant and Young Children Feeding Policy and Strategy. But it said that this had not translated into results because “to date neither policy has been effectively implemented”.
Developing, legislating, disseminating and enforcing national standards is one of the key components of the fortification project, said Van Ameringen, especially since 60-70 percent of the wheat flour and 90 percent of oil consumed in the country comes from imports. Talks with importers from neighbouring countries have already started, he said.
Ultimately the end goal of the fortification project is sustainability.
For example, the millers participating in the project will not profit immediately, says Carrie Morrison, WFP's director of health and nutrition, but the potential to make money will grow as the government standardizes the process.