The First 1,000 Days

PART ONE      PREGNANCY

chapter one

UGANDA

TO THE NEW MOMS AND MOMS-TO-BE GATHERED ON THE veranda of the Ongica health post in northern Uganda, midwife Susan Ejang seemed like a modern-day incarnation of the Angel Gabriel, who two millennia earlier had appeared to one particular young woman with the message that she would give birth to the Son of God. Susan’s message that their offspring could achieve great things wasn’t quite that momentous, but it was certainly a bolt from the blue. And it also required a leap of faith. For generations, mothers here had not dared to dream of such things for their children, so tormented was life in northern Uganda. In fact, many of these young moms now on the veranda considered themselves fortunate to have merely survived their own childhood. Up until a few years earlier, they and many other villagers routinely scurried through the bush like field mice to escape the terror of the warlord Joseph Kony and his thieving, kidnapping, murdering gang called the Lord’s Resistance Army. The LRA aimed to topple the government and establish a theocratic state based on the Ten Commandments while breaking every one of them along the way: raping, murdering, stealing, pillaging, abducting thousands of children to serve as soldiers and sex slaves. At night, mothers and fathers fled with their children to the rocky hills to sleep under the tenuous protection of Ugandan army troops. During the day, girls and boys sat nervously at their school desks, jumping at any loud noise that might signal the beginning of an LRA raid. Rural villages disappeared as residents fled to refugee camps near bigger, slightly more secure cities, such as Lira. One night, in the town of Aboke, down the road from the Ongica health post, 139 girls were abducted from a Catholic school and taken to LRA camps deep in the bush.

It was into this brutal world that mothers delivered their children. The goal was simply survival. Who could dream of anything, especially greatness, beyond their daily nightmare?

Esther’s parents prayed that their daughter would stay beyond the reach of the LRA and out of harm’s way in the Nile River marshlands where they lived, just south of Lira. The parents of her husband, Tonny, had spent four years on the move to secure the safety of their children, first doing the nighttime shuttle up the craggy hill called Apila and then moving into a camp. Esther and Tonny knew one thing as they expected their first baby: living in fear, terrified of what might happen each day, was no way to raise a child.

Although Kony had fled the area several years earlier, perhaps for the jungles of Congo or the Central African Republic—no one knew precisely where—the years of LRA terror, and the brutality that had preceded them throughout the country, still haunted northern Uganda. Since independence from British rule in 1962, Uganda had endured a series of coups and conflicts and governments of kleptocrats, thugs, and murderers (exhibit A: Idi Amin, who murdered thousands and stole millions) that had scarred the country’s beauty and largely squandered its natural abundance. As the twentieth century came a close, the Pearl of Africa had become the Peril of Africa.

One of the legacies of a half century of upheaval was widespread malnutrition and a woeful health-care system that particularly jeopardized the early years of life. Even now, in the second decade of the twenty-first century, Uganda’s neonatal mortality rate of 27 per 1,000 live births, infant mortality rate (deaths within the first year) of 54 per 1,000 live births—and worse, 66, in the northern district—and the under-five death rate of 90 per 1,000 live births (about 170,000 children in total), along with a maternal mortality rate of 438 per 100,000 live births, were among the worst in the world. These numbers represented big improvements since the 1990s, but they still put the country “in the top ten”—in other words, at the bottom—of a combination of these woeful categories, as described in a candid assessment released by Uganda’s minister of gender, labor, and social development, Wilson Muruuli Mukasa, and UNICEF.

The report, Situation Analysis of Children in Uganda, painted a bleak picture of maternal and infant health. The immediate causes of infant mortality were hypothermia (37 percent), premature birth, and pneumonia and infections, with malnutrition being an underlying cause of 40 percent of all under-five deaths. The main direct causes of maternal mortality were hemorrhage (42 percent), obstructed or prolonged labor, and complications from unsafe abortion; indirect causes included malaria, anemia, and HIV/AIDS. Vitamin A deficiency was found to afflict about 40 percent of all children under five and about one-third of all women of childbearing age, while anemia plagued about half of all children between six months and four years of age and 60 percent of pregnant women. The report estimated that Uganda lost nearly $1 billion worth of productivity every year due to high levels of stunting, iodine deficiency disorders, iron deficiency, and the lifetime impact of low birth weight.

“Staggeringly low” was how the report described the availability of basic health services, especially in rural areas. Only about half the country’s pregnant women had access to good-quality prenatal-care services, and only 57 percent of babies were delivered in a health facility. In 2011, barely half the children one or two years old were fully vaccinated in the country—despite the government’s goal of full immunization. One-quarter of children under four years of age were said to be living in extreme poverty and experiencing profound deprivation.

These were unlikely conditions for producing much greatness. But Esther had reason to believe she was one of the lucky ones, a woman soon to deliver her first child at the time her country had made improving nutrition and reducing stunting a top national priority. “Our children’s cognitive development represents Uganda’s greatest natural resource,” Minister Mukasa had written in the foreword to the Situation Analysis. He noted that Uganda’s ambition to become a middle-income country by 2040 remained “highly contingent” on the country’s children having the best possible start in life.

The women gathered on the veranda of the Ongica clinic were new moms bringing forth a new generation of children—and expectations. Focusing on the 1,000 days was an essential part of the government’s Nutrition Action Plan, a document that conveyed a palpable urgency that the nation’s future was in the balance. Uganda’s stunted children, it reported, had 1.2 fewer years of education than did healthy children. More than half of the country’s current adult population had suffered from stunting as children, and as a result these adults were less productive in their jobs and earned lower wages than those who had not suffered from stunting. The combined cost associated with child undernutrition—health-care expenses, lower education, lost productivity—was one of the main factors keeping so many Ugandan families, and their entire country, poor. “Eliminating stunting is a necessary step for sustained development in the country,” the report concluded. It was one of the first African documents to embrace the importance of the first 1,000 days.

Esther eagerly stepped up to the front lines to put the plan into action for herself and her baby. She had toiled in the fields all morning, tending to her crops, bending deeply to turn the soil and remove the weeds with a hoe. She was especially proud of two particular plots: her orange sweet potatoes, rich in vitamin A, and a new variety of beans that had a higher-than-normal iron content. Before heading off to the health clinic for the lesson with Susan, Esther had washed the dirt from her feet, legs, and arms and put on clean clothes. She chose her favorite new shirt, which hung loosely on her tall, thin frame. The polo-style shirt was bright orange and proclaimed this message on the back: “Prevent Vitamin A and Iron Deficiencies. Plant and Eat Orange Sweet Potatoes and High Iron Beans.”

The shirt was a gift from HarvestPlus, an international research program that was pioneering the fortification of staple crops, a new wave in agriculture that, through conventional breeding, raises the nutrient content of the food people eat every day. It was one of the imperatives of the 1,000 Days movement, bringing agriculture and nutrition together in a marriage called “nutrition-smart agriculture.” The program, which was endorsed in the Nutrition Action Plan, had been introduced to the rural areas around Lira by HarvestPlus and the international humanitarian organization World Vision just two seasons before. Esther readily embraced the new crops. The timing for her, she believed, was wonderful, the planting in sync with her pregnancy. The harvest would coincide with the birth of her child. The vitamin A and iron would help keep her strong and give her baby a good start in life; the nutrients would enrich her breastmilk and then also the baby’s first solid food of mashed-up sweet potatoes and beans. She was practicing what Susan was preaching.

“Who is planting these crops?” Susan asked the women on the veranda.

Esther enthusiastically and proudly raised her hand. “I am,” she said. Dozens of arms shot up and waved across the veranda. Most everyone was in on the program.

“Don’t grow them just to sell,” Susan instructed. “You and your families must eat them. Vitamin A and iron are important for your child’s growth.”

I HAD FIRST met Esther the day before in the village of Barjwinya, under a giant mango tree. It was the local gathering spot to discuss matters of importance. The tree was at the center of a cluster of square one-room mud-brick houses with thatched roofs. On this day, families had migrated to this shady spot from miles around, walking along the dirt pathways from their small settlements.

They had come to celebrate the HarvestPlus program and to learn more from World Vision instructors based in Lira. As the World Vision staff arrived, they were greeted with dancing and clapping and joyous shouts as well as the high-pitched trilling ululation central to an African celebration. A chorus of women decked out in orange T-shirts and skirts welcomed their visitors with a swaying song of greeting, a verse for each. The most animated praise was lavished on the orange-flesh sweet potato and the high-iron beans. They were the newcomers that had changed the village. Ekyokulya Ekyobulamu, proclaimed the slogan on the women’s orange shirts. Good Food Good Life.

Pregnant women and mothers with little children sat on reed mats at the base of the tree, in the center of the shade. They warily eyed the large, round mangoes hanging above them, which were nearing peak ripeness and would be falling soon. Eating the fruit would be good for their health, but the mango season could be hazardous as well. You didn’t want one clanking you or your child on the head as it fell. A dozen chickens and one rooster scratched the dirt around the tree. The men stood on the fringe of the gathering, just within the shade cover. Together, women and men, they called themselves Ocan Onote: The Poor are United. The village’s very name indicated a history of misfortune: in the local Langi language, Barjwinya means “place of jiggers,” referring to a past infestation of the parasitic fleas that burrow into the skin, causing infection and great pain.

But this was a day to celebrate a hopefully brighter future. A line of blue plastic chairs was arranged for the elders and the visitors. We sat behind wobbly little wooden tables neatly covered with blue and white doilies. It was a big day for the villagers. From their humble little houses, they brought out the best furniture they had.

First to speak were the elders of Barjwinya, who regaled the gathering with tales of how their eyesight and general health had improved since the introduction of the vitamin A–enriched sweet potatoes. One man insisted he could now see visitors entering the village from a far distance; before they were just blurry ghosts. Another man proclaimed his eyes had stopped watering and he didn’t need his glasses anymore. A woman who had lost her front teeth, top and bottom, and almost all her sight, said that before the orange sweet potatoes, she had given up sewing because she couldn’t see well enough to thread the needle. Now, she joyfully told the gathering, she was threading again! And she was back sewing. The oldest member of the group, a woman who proudly proclaimed her age of eighty-seven years, to great applause, said, “I didn’t see well, especially at night. But now I can see much better. I can see that Roger is sitting there, and he is white!” The laughter nearly shook the mangoes off the tree.

The elders then encouraged the young women, those expecting and those with babies, to speak. At first they described conditions before the arrival of the new crops: pregnancies marked by tiredness, dizziness, miscarriages; babies often sick, listless, cranky. “Tired blood” was their common diagnosis for both moms and babies, confirming the country’s statistics showing that anemia was a national malady. One woman said her first two children had each needed a blood transfusion at about six months of age because they were so anemic. But, she added triumphantly, her youngest child—born after the arrival of the sweet potatoes and the beans—had reached the age of one without any illness.

Eveline Okello sat on a reed mat, breastfeeding her one-year-old son Joshua. “There’s a very big difference between this child and my others,” she said. “I notice I have more breastmilk for this one.” Joshua had four siblings. He was barely one month old when he was riding on his mother’s back as she planted her first orange sweet potatoes and then her maiden crop of high-iron beans. When he was six months old, the harvest was in, and the sweet potatoes and beans were the first solid foods that he ate. “This child isn’t sick so often,” Eveline said. In fact, he was so robust neighbors had taken to calling him “little President.” Her other children, Eveline noted, had “coughs, malaria, the flu, headaches. But I haven’t suffered with Joshua at all.” One of the elderly women piped up again to say the area children were quite rambunctious. “Ooooh, they develop very fast now,” she said. “They aren’t dull.”

Grace Akullu, the World Vision nutritionist in Lira who worked with the women as they harvested and consumed the new crops, asked the pregnant moms if they were taking their iron and folic acid supplements. The women reported that the supply of the tablets at the local health post was inconsistent. Sometimes they were available, sometimes not. Instead of receiving a batch of thirty for one month, one woman said she only got fourteen. “Four,” said another mom, that’s all she had. A third woman said she was only given malaria tablets; she hoped they would be a general cure-all. Even if women received the required number of tablets, there wasn’t much follow-up to make sure they took them. The government standard of prenatal treatment was four checkups, but many women just went two or three times, depending on their distance from the health post. Grace, who was pregnant herself, noted that women sometimes stopped taking the iron tablets because they didn’t like the taste, or because it made them feel ill or become constipated. A common attitude was, I’m feeling fine, why bother taking something that doesn’t sit right with me? They didn’t understand the health benefits.

The new crops, which the women would eat almost every day after the harvest, provided a more consistent dose of micronutrients. The amount of iron and vitamin A the food provided may not have met international recommended amounts, but it was certainly more than they had been getting before. And the moms believed in the health benefits of the new varieties of crops.

Brenda Okullu, stylish in a gold dress and a maroon scarf wrapped around her head, said she was feeling much better with this pregnancy, her second. She was six months along, and suffering fewer headaches than she had the first time. She had more energy and expected to be working in her sweet-potato and bean fields right up to the time she would deliver. She thanked World Vision, and the new crops, for her added pep. It must be them, Brenda told Grace; nothing else had changed. “Right now I’m feeling good,” she said. “The baby kicks a lot. My life is good.”

A shy smile brightened Brenda’s cherubic face. Grace was happy to see that, for she knew that Brenda had experienced deep sadness. Despite the smile, Brenda spoke and moved as if carrying an invisible burden; her voice was soft, her head bowed. She began to recount the story of her first pregnancy, two years earlier when she was eighteen. The pregnancy had been difficult. She was always tired, dizzy, suffering headache after headache. But she carried her baby to full term and delivered at the Lira hospital. The baby was healthy and began breastfeeding immediately after birth. The new arrival brought great excitement and joy in her family compound of little thatch-roofed huts. A week after the birth, though, Brenda was still in considerable pain: her ribs and back were sore, and those headaches continued to pound. She had an appointment scheduled to bring the baby to Susan Ejang’s clinic in three days, but her pain became so acute that she returned to the Lira hospital, this time to the emergency ward. She was breastfeeding, so she brought the baby with her. The nurses checked Brenda into the hospital for treatment of anemia. They told her she needed rest.

While Brenda recuperated, her baby began fussing and crying; breastfeeding was difficult. The doctors suspected an infection of some sort, but they had little time to investigate the cause or medication to combat it. Brenda was feverish with fear: Was she losing her firstborn? One night, the baby stopped crying. Then the baby stopped everything.

Within two weeks of birth, her child was dead.

“I don’t know why,” Brenda said. Then she fell silent. That would be all she would say about her first child. It was all she could say. She knew nothing more; no one had given her an explanation. Tears welled in her eyes as she looked away, first staring into the soil and then looking into the distance.

No one spoke for a minute or two as the community shared in her sorrow for her lost child. Then another mom, Harriet Ogwal, filled the silence with a hopeful note. “I see things getting better,” she said. Harriet was newly pregnant with her fourth child. She was older than Esther and Brenda, about twenty-seven (she didn’t know for sure), and a voice of experience for the younger women; her children were ten, eight, and five years old. Harriet knew the importance of good nutrition. During her three earlier pregnancies she and her husband, Moses, could rarely afford any food beyond what they grew themselves. She was often sick with malaria, nausea, or general weariness. And the children were frequently ill as well. Now, bolstered with a better home-grown diet, thanks to the orange sweet potatoes and the beans, she said this pregnancy was her best yet. She anticipated being able to work in the fields, tending to her fortified crops, until the day of delivery. “During previous pregnancies, I’d fall sick over and over. So much malaria,” she said. “Now I have more energy to do the planting and a better appetite for food.”

Suddenly, from out of the bush, a man stumbled into the gathering, demanding his dinner. “Where is it?” he bellowed. “Why is it late?”

The crowd under the mango tree erupted in laughter. Clearly the man was drunk—or was pretending to be. In fact, his appearance was the beginning of a play. Community theater had proven to be particularly effective in conveying messages to areas where many of the residents were illiterate. World Vision and HarvestPlus also used the nation’s network of local radio stations, developing scripts for short spots and a call-in show. But bush drama was more intimate; the actors were neighbors, the language their own. It was also great entertainment.

The drunk’s wife, hurrying to offer up an explanation why dinner wasn’t ready, said she was feeling sick, tired, and dizzy; she was not seeing well, and her head was pounding. “Well, then,” her husband insisted, “you must go to the hospital.”

The scene shifted. The wife was now facing a doctor. She repeated her symptoms as the doctor looked under her eyelids. Anemia, he declared. “You should go back to your community and join a group growing high-iron beans that are good for the blood and also the orange sweet potato for vitamin A.” Don’t fear the orange, he advised; it is an indication that the potato is full of beta-carotene, which the body turns into vitamin A. And vitamin A is good.

Back home, the wife told her drunk of a husband that World Vision was distributing orange-flesh sweet-potato vines and high-iron bean seeds in their village. They should get in on the program, she suggested. The husband angrily waved off the idea.

“We have been planting beans and sweet potatoes all these years and there has been no improvement in health,” he complained.

“But these sweet potatoes are orange, not white like our usual ones,” explained the wife. “The orange helps to improve eyesight, boost the immune system, soften the skin. And the beans, they may look the same, but they have more iron, which will help our blood.” The husband perked up at the mention of softer skin for his wife. “If it will make us better,” he conceded, “we should plant them.”

Next, the man began strategizing about where to plant the new crops. He paced impatiently, grumbling, “We are ready. Where are the vines and the seeds?”

A World Vision worker appeared and demonstrated how to plant the new crops. Place each sweet-potato vine in a mound of dirt, not just flat soil, he said. The beans need proper spacing, fifteen to twenty centimeters between holes. If you plant them too close together, the beans will have to compete for soil nutrients, sun, and water. “Just like if you have ten children in your house and your neighbor has two. The two will grow up to be healthier than the ten, because ten are too many to care for.” It was a family planning message thrown in for good measure.

The scene shifted to the post-harvest period. The wife emerged from a hut carrying a bowl of orange sweet potatoes, and a group of children pounced on it, pushing and tugging at each other to reach the treat. One girl victoriously held a potato aloft and shouted, “Look what I got!”

In a market scene, a seller hawked the sweet potatoes. She also hoisted one above her head for all to see. “This is full of vitamin A. It’s very healthy.”

Another vendor shouted, “I have beans high in iron, they help your blood and brain development.”

A woman selling regular black beans complained to customers: “Why aren’t you buying these?”

A customer scoffed, “We don’t want those beans anymore. The other ones are healthier.”

The drunk reappeared, but now he was sober, cleaned up, robust, strutting. He announced to his family, “Do you see the change in me? I’m a better man now.”

His mother congratulated him for using the money he once spent on booze to purchase bean seeds and sweet-potato vines and to provide more nutritious food for his family.

In a final scene, the wife and husband, now wearing orange T-shirts, were back at the hospital, thanking the doctor for his advice about the new crops. They and the other cast members launched into a closing song:

                The new crops are feeding us well.

                Very nutritious, very wonderful.

                The high iron beans have saved our lives.

                The orange-flesh sweet potatoes have saved our lives.

Esther joined in the applause and laughter. She, too, was grateful for the new crops and their promise of better health for herself and her child. She slowly rose to her feet, lifted by the optimism of the gathering, and began the long walk back to her fields, to tend to her beans and sweet potatoes. As did Brenda and Harriet and the rest of the crowd. But a nagging thought remained hanging under the mango tree in the village named for a plague: Could this agricultural innovation truly conquer their poverty and lack of development? Or would it, eventually, be the other way around?

chapter two

INDIA

IN A RURAL VILLAGE IN INDIA, THE POSSIBILITIES OF THE 1,000 days were also praised in song. “Light the lamp of knowledge in every home, transforming our weakness into strength,” sang a chorus of pregnant women and new moms in their Hindi dialect.

                If you take care

                you’ll need no medicine

                and won’t need to spend a penny.

                Before delivery, tend to the mother,