In “When Reforms Don’t Transform: Reflections on institutional reforms in the Department of Education” written by Ma. Cynthia Rose B. Bautista, Allan B.I. Bernardo, and Dina Ocampo, mention was made of something beyond the control of DepEd, something which has essentially laid its efforts at education reform to waste:
“While this… examines institutional factors that have constrained the transformative effects of education reform, it recognizes that some reforms would not necessarily translate into desired outcomes when the intervening variables are not within the control of DepEd. For instance, studies conducted by the World Bank and the National Nutrition Council have shown that no amount of academic improvement projects will improve learning achievement when brain development and physical growth are stunted by the child’s unfavorable health and nutrition status.”
In other words, IT’S THE FOOD, STUPID!
It’s the appropriate nourishment for the woman about to become a mother–planned or unplanned, it’s the nourishment the expectant mother imparts to her child from conception till birth, it’s the nourishment the child receives from birth to age 3 and beyond within which the child’s brain is in critical development. MIND YOU, IT’S NOT JUST RICE PORRIDGE!
In the DepEd’s “School Milk Project” to supplement the diet of undernourished school children, all Grade I pupils in selected schools are served chocolate flavored milk for 120 feeding days developing in them the mild drinking habit and improved nutritional status. Through its “Breakfast Feeding Program,” DepEd aims to improve the active learning capabilities of school children through provision of breakfast among Grade I pupils in selected schools in the form of specially formulated noodles containing 300 kilo (?) calories, 10 grams protein and 800 IU beta carotene, fortified with iodine. By all empirical accounts, these remedial nutritional interventions are late, assuming the child’s age of critical brain development starts from the fetus to age 2-3, with remedial intervention to occur up to age 5! Although remediation by proper nutrition may still occur after age 5, the “School Milk Project” and “Breakfast Feeding Program” had such a narrow clientele to have an effect nationwide.
The literature abounds with empirical and not so empirical studies suggesting nutrition or the deficiency thereof (malnutrition) as having a critical effect on the would-be mother, her child’s fetal brain development and thereafter. Here’s an excerpt (Chapter 2) from “Efficient Learning for the Poor: Insights from the Frontier of Cognitive Neuroscience” written by Helen Abadzi:
Health, Nutrition, and Cognitive Processing
Malnutrition and ill health may significantly damage the cognitive processing ability of poor students. Students whose processing capacity is affected by ill health and malnutrition may require more hours of instruction to learn various skills. Early childhood education, along with health and micronutrient supplementation for school children, may prove critical in achieving Education for All in low-income countries or areas. These very effective interventions require close and sustained collaboration between ministries of education and health. Means must be found to facilitate their execution.
To the Western visitor, students in low-income countries seem very small for their age. They also tend to be quiet and well behaved. While such classrooms may appear to be conveniently manageable, all is not well with many of these children.
To function, neurons require energy that is obtained when the body metabolizes glucose and delivers it through the blood to the neurons along with oxygen. The various stages of the glucose-to-energy conversion require oxygen, vitamins, minerals, and micro-nutrients. Nerve cells are partly made of essential fatty acids that are obtained from food, so these substances are essential for brain development and learning. Not surprisingly, well-fed and healthy nerves are required for efficient brain function and learning. This is why early nutritional and health interventions are needed for the poor. As the Education for All initiative brings to school the most vulnerable populations, the chances increase that some students will have neurological damage that affects information processing capacity. Some types of damage can be mitigated and others cannot. Some have larger effects than others, but multiple sources of damage make cognitive deficits add up. The literature on these subjects is vast; only highlights leading to school health interventions are discussed below.
Health and Nutritional Obstacles to Learning
The poor are at risk for cognitive processing problems from multiple sources that interact with each other. As a result these multiple factors, perhaps 40 percent of children younger than 5 years in low-income countries may have stunted growth.1 Such factors are likely to affect the neural systems mediating attention and memory.
Early risks for diminished cognitive processing include difficult births, low birth weight,2 and exposure to toxins, such as arsenic and lead, which affect the ability to plan. Home violence3 seems to wire the grain to react in certain ways and interferes with consolidation of certain types of memories. Serious infections may result in lower measured intelligence quotient (IQ) and impaired visual-motor functions.4 Contaminated water has considerable health consequences for children.5 Repeated intestinal infections (such as giardia) particularly in the first two years of life may reduce cognitive ability, as dehydration caused by diarrhea results in reduced blood flow to the brains of young children. Parasites such as hookworm, schistosomiasis,6 and malaria may cause chronic anemia. Chronic worm infestations, sometimes due to poor school sanitation, drain children’s nutritional resources, resulting in impaired memory and reasoning, and a loss in measured IQ.7 Healthier children are more likely to go to school, and treatments reduce absenteeism.8 A one standard deviation increase in child health increases achievement test scores by about one-third of a standard deviation of that score—the equivalent of spending eight more months in school, which implies a benefit-cost ratio of at least three.9
Health and School Attendance
A rigorously studied Mexican program paid poor mothers a small sum if they kept their children in school and got them immunized. A large randomized trial, published in 2001, showed that the children who participated were healthier and stayed in school longer. Healthier children are more likely to go to school.
Providing poor students with free uniforms or a simple porridge breakfast substantially increased attendance in Kenya. On the other hand, giving students drugs to treat the intestinal worms that infect more than a quarter of the world’s population was more cost-effective, with a price tag of only US$3.50 for each additional year of schooling achieved.
Sources: Dugger 2004; Kremer and Miguel 2001.
Physical and mental health problems may push students into the special education category. Though there are few surveys, the schools of the poor may have a number of students with borderline retardation or reading and learning disabilities. For example, between 11-18 percent of children in Central America have disabilities, but less than 10 percent of them receive educational services.10 Even students who are only physically handicapped may be involved in fewer activities and may have fewer skills. The challenge is to adapt curricula and instruction to meet special needs in low-income countries.
Overall, food insecurity has specific developmental consequence for children.11 The diets of young children in developing countries often are of low quality in terms of energy and nutrient concentrations; as a result, multiple nutrient deficiencies are common.
Some examples of nutrient deficiencies and their effects are offered below.
Essential fatty acids (found in animal fats, fish oil, and plants such as evening primrose) are required for brain development. Young infants should receive these through breastfeeding. However, the very poor may eat very few fats and rely on a diet of a single stable, such as millet. Children who rarely or never eat meat, or live away from coastal areas where fish is available, may be at risk for learning and reading difficulties as well as delays in motor development, attention deficit, and behavior problems.12 A study undertaken in Norther Ireland using a daily nutritional supplement with an appropriate fatty acid balance showed significant reading improvements.13
Micro-nutrient malnutrition is a pervasive and debilitating problem and it is more severe when children are small and younger and the mothers less educated.14 Iodine deficiency in areas of heavy rainfall (as in Bangladesh) is associated with reduced intelligence; even moderate forms of iodine deficiency lead to the loss of 10 to 15 IQ points.15 Zinc deficiency can also be significant.16 Low iron and the resulting anemia adversely affect attention17 and cognitive ability, resulting in significant productivity loss.18 Anemic women make double the errors in a memory task than an iron-sufficient group and take longer to do tasks.19 They also lack nutrients to transmit to their children during pregnancy. Iron deficiency significantly affects brain development by age 2; it is widespread, particularly among girls.
Protein-energy malnutrition (common in Africa) also affects girls’ cognitive functions disproportionately, including the ability to learn categories, process and structure information, learn and react to social and environmental cues, and identify and solve relevant problems. In Mali, for example, 38 percent of children were found to have moderate or severe stunting, while 65 percent had moderate or severe anemia.20 These multiple sources of malnutrition may also constrict the growth of the head size during rapid brain growth and affect intelligence.21
Malnourished children are sick more often, are susceptible to infections, and are more likely to drop out of school.22 Several studies using longitudinal data and special features to identify causal effects have found a link between poor pre-school nutrition and school achievement.23 In one study, Jamaican children who were malnourished or had stunted growth scored 10 points less in an IQ test than children of normal weight and height.24 In another study, malnourished children from Mauritius scored 15.3 IQ points less compared to controls by age 11, and the nutritional status was linked to a considerably higher incidence of aggressive behaviors and hyperactivity.25
Studies find both delayed school initiation and fewer grades completed for malnourished children, as well as negative consequences for performance on cognitive tests as adults.26 Malnourished children enter school later and perform more poorly on cognitive achievements tests. Malnutrition in the first six months can be reversed, but the second year of life is critical due to rapid brain development.27 The effects of malnutrition cannot be mitigated after age 2 or 3 and cannot be compensated by improved nutrition later. The challenge is to reduce early malnutrition, preserve cognitive processing power, and also reduce later antisocial and aggressive behavior.28
School feeding programs may not mitigate early malnutrition but in principle are highly desirable, partly because they attract school children who are chronically hungry.29 Food during school hours, particularly breakfast, may improve concentration, particularly in chronically deprived children who have limited excess stores of energy. Malnourished children in Jamaica who had not eaten breakfast performed less well than controls on working-memory measures (digit span), problem solving, and fluency.30 However, feeding programs cost a lot, may create economic distortions in local markets if food is imported, and have a large potential for mismanagement. More limited interventions, such as providing fruit or highly nutritious biscuits and milk, proved affordable in countries like the Dominican Republic.
Several donor-financed projects have attempted nutritional interventions such as micro-nutrients, deworming, and vitamin A with encouraging results. Eyeglasses may also be provided. In principle, reaching children in schools with essential treatments is efficient, given the frequent public-health difficulties of bringing the population to centers for health interventions. It is feasible to distribute to schools pharmaceuticals that need to be administered once or twice a year such as albendazol for deworming and vitamin A. Other interventions, however, such as iron require daily or weekly administrations and are harder to program. As a result, the logistics and management of various interventions become complex. Problems have been known to arise with pharmaceutical procurement, worker absenteeism, poor communication of health messages, and inadequate coordination between health and education ministries.31 Thus, beneficial interventions can be compromised by imperfect delivery mechanisms.
Developmental Delays and the Importance of Preschool
With fewer opportunities to learn skills useful in school, low-income entrants to grade 1 may lag behind better-off children in terms of psychomotor development, reasoning, complex grammar, and vocabulary. Poor parents do not talk to their children as much as middle-class parents, and when they do, they use simpler phrases with limited vocabulary. In the United States, a socioeconomic gap in vocabulary is often established by age 3 that affects reading skills and is hard to remedy.32
The poorer children may simply lack the cognitive networks and prior knowledge to which they can attach school-related information. Teachers may pay little attention to immature children, who may fall further behind. Grades 1-2 in effect screen out many such children in low-income countries, who drop out of school illiterate by grade 3. Parents in response may send children to school when they consider them ready, often at ages 8-10. Over-age enrollments may be to some extent due to the cognitive delays caused by long-term malnutrition and ill health.
Stimulation results in new brain tissue and nerve connections and thus may help children who suffer nutritional deficits early in life. The principle behind early childhood development (ECD) and preschool education is to reach children as early as possible with nutrition, health interventions, and stimulation, so that they can later benefit from primary education. In recent years, several programs have been implemented in low- to middle-income developing countries. Examples include the U.S. Head Start program, Bolivia’s Integrated Child Development Project, Colombia’s Community Child Care and Nutrition Project, Indonesia’s Early Child Development Project, and India’s Integrated Child Development Project. World Bank projects have also helped train caregivers and educate parents. Examples include Mexico’s Initial Education Project, Chile’s Parent and Children Program, Uganda’s Nutrition and Early Childhood Development Project, Kenya’s Early Childhood Development Project, and the Philippines’ Early Childhood Development Project. Studies have been carried out in countries such as Bolivia, Jamaica, Guatemala, the Philippines, and the United States.33
Studies overall suggest positive effects from the various interventions on children’s health, nutritional status, and psychosocial development. These effects may result in higher achievement test scores and graduation rates and in lower grade repetition, special education needs, crime rates, and delinquency. For example, a 20=year study in a rural area of Guatemala combined data on early biological indicators, graduated parameters of social structure, and preschool cognitive assessments into a risk scale, and analyzed the data in relation to primary school grade attainment and adolescent psychoeducational test performance. Performance declined with the number of risk factors to which a subject was exposed. However, brain stimulation was also an important factor, and primary education buffered the effects of early risk. Children at high risk who stayed in school performed significantly better than those with similar levels of risk who completed fewer than four years of primary school.34 Similarly, the Abecedarian project in the United States showed that early childhood education has a powerful influence on poor children that lasts into young adulthood, affecting things like reading and mathematics skills and even the timing of child-bearing. Children who received high-quality day care consistently outperformed their peers who did not on both cognitive and academic tests, and also were more likely to attend college or hold high-skill jobs.35
Implementation challenges. Early childhood donor interventions tend to be complex operations that disburse small amounts of money to large numbers of users and need considerable monitoring. Countries must provide standards, information, and staff training, but many have not yet developed the institutions needed for such interventions. The programs also need strong national support to become financially sustainable as well as incentives to civil society and local governments for the development of new providers, such as mothers in home-based programs (as in Colombia and Bolivia).36 This strategy implies cost sharing by communities through a mixture of block and matching grants. With limited institutional strength, outcomes in lower-income countries are more subtle and modest than would be expected.
Thus, despite efforts to finance early childhood development and kindergartens in many countries, the vast majority of poor children remain unserved. A child in sub-Saharan Africa can expect to receive just 0.3 years of pre-primary schooling, compared to 1.6 years in Latin American and the Caribbean and 2.3 years in North America and Western Europe.37 Yet in the United States, investments in low-income children’s preschool have a high payoff. The average cost per child may be US$6,000-12,000, but the savings in terms of later services have been estimated at about US$30,000-120,000.38
The unmet need for language complexity. Despite successes, preschool programs often fail to close the gap between the poor and those who are better off. One reason may be that the effectiveness of activities is unknown. Though curricula are based on developmental concepts, it is unclear how they are implemented. Children are often observed playing with educational toys and interacting among themselves, but these activities may not be what the poor need. According to some researchers and practitioners, the critical skill to develop during preschool years is language vocabulary and complexity. Children learn language interactively, which means that an adult must interact with them individually rather than just within a group.39 To prepare for reading a language with complex spelling (such as English or Urdu) they need exercises to recognize sound segments (called phonological awareness exercises). Children will benefit from training to recognize compound words, delete initial and final phonemes, and understand rhymes. However, many day care workers are themselves poor and have a limited knowledge of language. The challenge is to train day care workers of limited education to scaffold children’s language through simple games, pairing them up for increased communication rather than keeping them in a group, and talk to each child individually.40
Preschool education is clearly desirable, but what can be done when students arrive in primary schools without this training? Some middle-income countries, such as Uruguay, offer compensatory programs.
Interventions in health and nutrition are necessary, starting even before birth if possible. Because selective feeding is expensive, an integrated approach is needed to ameliorate nutrition problems. Part of this approach is providing information to parents who simply may not know that their children must eat before school.
Early childhood development and education interventions may help overcome developmental delays. During the school years, poor children may benefit from longer school days and extra help with school work. They should receive school health inputs such as eyeglasses and micro-nutrient supplements along with school feeding if possible. The difficulties of these operations must be dealt with cooperatively between the health and education sectors. Donor procurement procedures must be harmonized. Health intervention costs have not been included in the Education for All financing simulations, but the pharmaceuticals are not expensive. More important are the management problems that must be overcome if interventions are to be implemented in a sustainable fashion.
Research needs. Although school health and nutritional issues have been studied extensively, there is little information on the interactions of nutritional, developmental, and educational variables. Many issues must be clarified, such as the relative importance of instructional time versus stunting-wasting effects on reading fluency, how much extra instruction is needed to offset the cognitive deficits created by health issues, and additional costs to educate poor students in low-income countries. Most important, research must determine through randomized experiments what intervention combinations will be most cost effective in various countries.
Limited learning among the poor is not just a problem of low-income countries. The young generation in many industrialized or middle income countries disproportionately comes from poorer families that have more children. To maintain their high-level human capital, countries like Uruguay and Brazil must adequately budget for and educate large numbers of poorer students. One means is to keep students in school most of the day.
In the full-time schools of Uruguay, the day lasts 7.5 hours and includes two or three meals usually cooked on site. Students carry out the regular school curricula in the morning and work on various projects in groups in the afternoon. In the early afternoon, children play games like chess, checkers, ludo, and sports. Later they form groups of mixed ages and carry out workshops on expression, mathematics, sciences, computer use, language, and social studies. There is no homework time, and the long hours do not permit much formal homework in the evening. By contrast, the secondary full-time schools of Pernambuco (Brazil) give students an hour of supervised homework.
Sources: OED 2005c; MECAEP 2002.
- Levinger 1992.
- St. Sauver 2001.
- Delaney-Black et al. 2002.
- Baum et al. 2004.
- Peruvian children living with inadequate water supplies and sanitation were found to be shorter and had more episodes of diarrhea (Checkley et al. 2004).
- King et al. 2005.
- Niehaus et al. 2002, Berkman et al. 2002, Jenkins et al. 1999. Jamaican children in grades 4-5 were treated either with placebo or an antiparasitic medication. All children were given a pretest and a posttest 10 weeks later to measure cognitive and fine motor skills. Compared to uninfected children, parasitic infection impaired performance on tests of memory and reasoning but not on tests of attention of fine motor skills. Treatment with albendazole did not remove the difference between initially infected groups. Therefore children whose cognitive functioning is impaired by whipworm infection need cognitive remediation and enrichment, not just medication, to recover lost cognitive functioning (Sternberg et al. 1997). The parasite load increases with age and iron deficiency seems to interact with parasitic effects.
- The World Health Organization has identified worm infections as the greatest cause of disease among 5- to 14-year-old children. So, many school health programs successfully provide deworming medicine. For example, school-based mass treatment of children for hoodworm in Kenya was shown to reduce student absenteeism by one-quarter (Kremer and Miguel 2001, 2004). In India, a program to provide iron supplementation and deqorming medicine to preschool students decreased absenteeism by 7 percent among children age 4 to 6 (Bobonis et al. 2002). A WHO study in Indonesia that investigated the association between helminth infection and cognitive and motor function in school-aged children found that children infected with hookworm scored significantly lower on tests of cognitive function in comparison to uninfected children (citations in Birdsall et al. 2004).
- Glewwe, Jacoby, and King 2001.
- Disability statistics can be found at http://www.iadb.org/sds/soc/site_6190_e.htm.
- Jyoti et al, 2005.
- Although limited data exist, children in low-income countries undoubtedly are affected by dislexia, autism, and coordination of fine movements (as is about 25 percent of the school population in OECD countries; OECD-CERI 2003b).
- EPA (eicosapentaenoic acid) as opposed to DHA (docosahexaenoic acid) appears to be most effective in these conditions; after three months of daily administration, children with reading difficulties, attention deficits, and delayed speech and more development showed considerable improvement (OECD-CERI 2003b). Also, fish oil has been found to reduce the incidence of attention deficits and behavior problems in British students (Richardson and Montgomery 2005).
- Block and Webb 2003. There are 39 substances that the body needs but cannot fabricate, so they must come from diet (OECD-CERI 2003b).
- Tezic 1998.
- Zinc was provided to seventh graders whose blood levels showed a deficiency. Those who consumed fruit juice supplemented with zinc reduced their reaction time on a visual memory test by 12 percent over 10 weeks, compared with 6 peprcent for students who received regular juice. They also had more correct answers on a word recognition test and better scores on a task requiring sustained attention and vigilance (Penland et al. 2003).
- Hulthen 2003.
- Horton and Ross 2003.
- Tamura et al. 2002, Levinger 1992. Iron-deficient women may take longer to do tasks and be less successful at executing them. Those classified as anemic make double the number of errors in a memory task than an iron-sufficient group. Giving women daily supplements of iron for four months reverses this effect (Beard and Wong-Rieger 2004).
- Gwatkin et al. 2000.
- Brain volume is positively correlated with intelligence (McDaniel 2005).
- Michaelowa 2001.
- Berhman et al. 2005. Children should be breastfed for two years, and they only need about 150 calories five times a day. But poor pparents often do not know how to feed their children (Rae Galloway, World Bank, personal communication, May 2005).
- Simeon and Grantham-McGregor 1989.
- Compared to a control group that did not have nutritional deficiencies, malnourished children showed a 41 percent increase in aggression at age 8, a 10 percent increase in aggression and delinquency at age 11, and a 51 percent increase in violent and antisocial behavior at age 17. The results were independent of psychosocial adversity and were not moderated by gender. There was a linear relationship between degree of malnutrition and degree of esternalizing behavior at ages 8 and 17. Low intelligence mediated the link between malnutrition and externalizing behavior at ages 8 and 11 (Liu et al. 2003, 2004).
- For example, Watson et al. 2001, Alderman et al. 2001, Alderman et al. 2003; Behrman et al. 2003.
- Glewwe and King 2001.
- Liu et al. 2004.
- In Bangladesh, school-based food distribution increased enrolment by 20 percent compared to a 2 percent decline in nonparticipating schools over the same period of time (Ahmed and Billah 1994). In Jamaica, Tamil Nadu, and other countries where school feeding programs were evaluated, attendance and retention generally rose (Simeon and Grantham-McGregor 1989; Babu and Hallam 1989). In Kenya, a randomized control study demonstrated that children’s school participation was 30 percent higher among students attending schools with feeding programs (Vermeersch 2002; see Bidsall et al. 2004 for citations).
- Simeon and Grnatham-McGregor 1989. Breakfast regulates metabolism, and children who go to school without it feel hungry all day (Dr. Kristy Nielsonk, personal communication, May 2005).
- IEG evaluations in Guinea and the state of Sao Paolo in Brazil are examples (OED 2002a, 2003b).
- A large survey study in the United States found dramatic black-white and social class differences in vocabulary by age 36 months. The gap stops widening when children enter kindergarten but remains constant; economically deprived children never truly recover (Farkas and Beton 2004). One possible reason is maternal malnutrition, given that malnourished mothers do not interact as much with their children or talk to them when they feed them (Rae Galloway, World Bank, personal communication, May 2005).
- See Behrman and Rosenzweig 2004; Currie and Thomas 1995, 1999; Karoly et al. 1998; Murnane, Willett and Levy 1995; and Neal and Johnson 1996 for the United States. See Alderman et al. 2001; Alderman, Behrman, and Hoddinott 2005; Behrman, Alderman, and Hoddinott 2004; Behrman et al. 2003; Deutsch 1999; Glewwe, Jacoby, and King 2001; Glewwe and King 2001; Martorell 1995, 1999; Martorell et al. 1994; and Young 1995 for developing countries.
- Gorman and Politt 1996.
- See, for example, Campbell et al. 2002 and newer publications. The project creates a high-stimulus day of art projects and playground visits. Examples of effective learning games include waving a scarf over an infrant until he or she grabs it, or leading a toddler to identify like items among several pieces of silverware.
- World Bank 2004.
- Global Monitoring Report 2005.
- World Bank 2004 (www.worldbank.org/children).
- Goodson et al. 2005, Farkas and Beron 2004.
- See, for example, Evans et al. 2000. Curricula for developing countries have been developed through the Christian Children’s Fund and the Step by Step program of Soros Foundation (and Children’s Resource International). Language-oriented curricula in the United States include Breakthrough to Literacy (a McGraw-Hill product with interactive software (www.breakthroughtoliteracy.com), Building Early Language and Literacy (BELL), LeapFrog SchoolHouse (www.leapfrogschoolhouse.com), Learningames (www.kaplanco.com/resources/article_Learningames.asp), Tools of the Mind (www.ibe.unesco.org/International/Publications/INNODATAMonograph/inno07.pdr), and the Indian Sonu Series Teacher Manual for Supporting Young Readers by Nag-Arulmani (www.thepromisefoundation.org/rpd_rk.htm).