Health, Nutrition, Care and Educational Performance
Good health and better learning outcomes are closely associated, according to a large number of studies. Additionally, the converse has been well documented, with worse educational potential linked to poorer health (shorter life expectancy, higher infectious disease rates and poor self-reported health) (Williams 1990; Winkleby et al. 1992; Woodward et al. 1992). Therefore in order to address key education obstacles, REAP is current focusing on malnutrition, specifically micronutrient (iron) deficiencies. (Additionally, Improving Vision for Better Educational Outcomes is another REAP focus area, given the high rates of school-aged children who need but do not have eyeglasses.)
The Perplexing Puzzle of Anemia in Rural China
Despite the rising incomes in China as well as government commitment to providing quality education, iron deficiency and anemia rates across rural China still remain high. Iron deficiency and anemia lead to compromised ability to learn and poor physical growth, which can impair school performance ultimately resulting in retarded cognitive, motor and academic ability. Recent 2008 and 2009 studies in Shaanxi, Ningxia and Qinghai Provinces have shown between 39 to 60% of school aged children in rural China to be anemic.
The Importance of Sufficient Iron and Education
According to the Food and Agriculture Organization, global hunger has increased since the 1990’s and reached 854 million undernourished people in 2008. In developing countries, approximately one of every three children under age five (167 million) is malnourished, and over 50% of child deaths are linked to malnutrition. Research efforts exploring malnutrition and human development began around the 1930’s, and have been further extended since then by studies focusing on the impacts of malnutrition on intellectual and cognitive abilities. For school-aged children insufficient nutrition, including iron deficiency, can negatively affect educational outcomes significantly through a number of ways.
Iron Deficiency Anemia
Iron deficiency anemia is a debilitating health condition which affects hundreds of millions of people worldwide, mostly in developing countries (Yip, 2001). Prolonged iron deficiency impairs hemoglobin production, limiting the amount of oxygen that red blood cells carry to the body and brain. As a consequence, anemia leads to lethargy, fatigue and prolonged physical impairment (and in the extreme form, severe anemia can be life-threatening because it reduces the body’s ability to tolerate trauma and bleeding). Moreover, a large body of research links anemia (and even iron deficiency not serious enough to impair hemoglobin synthesis) with cognitive impairment and altered brain function (Yip, 2001).
In addition to short and long term health consequences, anemia is doubly burdensome because it also has serious implications for the educational performance of those with the disease. Consequently, childhood anemia has been shown to be negatively correlated with educational outcomes, such as grades, attendance and attainment (Halterman et al., 2001; Stoltzfus, 2001; Stoltzfus et al., 2001; Miguel and Kremer, 2004; Bobonis et al., 2006). Early identification and treatment of anemia is crucial since without intervention these cognitive impairments can be irreversible, even after iron status is restored (Lozoff et al., 2000). Anemia may therefore limit children’s opportunities for social and economic mobility and may be an important contributor to the intergenerational transmission of poverty (Bobonis et al. 2006).
Challenges in Rural China
What is perplexing about anemia in rural China is that it is an exception to a commonly observed trend in a number of other countries. Generally, as rates of anemia and iron deficiency fall, incomes rise in an inversely proportional relationship. In rural China, average household incomes have risen, with agricultural commodity prices at all-time highs and unskilled, off-farm wages increasing. Policymakers have instituted a number of policies to benefit rural areas, including new grain and seed subsidies (liangshi butie), health insurance (NCMS) and the rural minimum living standard guarantee (liangmian butie).
Yet surprisingly, a significant share of children across China were still found to be so severely iron deficient as to be classified as anemic, based on a number of studies (Ministry of Health, 2002). According to a REAP study in 2008, a shocking 39% of fourth grade students in Shaanxi Province are anemic. A recent study of a rural junior high school in Shaanxi Province conducted by the provincial Center for Disease Control found anemia in as many as 40% of 5 to 9 year old students (Wang, 2008). Anemia rates in Qinghai and Ningxia Provinces are 36%, based on a REAP study in October 2009. A study in Guizhou found the rates to be 50 to 60% (Chen et al., 2005). Although some of these studies are small scale and non-representative, they still give rise to concerns that anemia may be a serious problem in rural China at least for a segment of the population.
There are numerous potential causes for the prevalence of anemia. In China’s poor Northwestern rural counties, there are a few prime candidates:
- Deficiencies in micronutrients and vitamins, including iron, are common and a challenge to healthy development for children. A child that wants to get rid of anemia needs a balanced diet of meats, vegetables, fruit and other foods on a regular basis, instead of a predominantly starch-based diet.
- Families in rural areas lack understanding about anemia; the majority of parents don’t know how to improve their kids’ diets in order to prevent anemia. Some families that have the means do not know how to or why they should provide a balanced diet for their child.
Parasitic Worm Infection in Rural China
Aside from dietary factors, intestinal worms can contribute to anemia according to the WHO, and have adverse consequences for education. A well known study by Kremer and Miguel (2004) shows that deworming in primary schools increased school participation and reduced absenteeism by over 25%. Therefore, in identifying the source of the problem in China, another piece of the puzzle is understanding the role (if any) that intestinal worm infections play in iron deficiencies among students in rural China. Although intestinal worms in rural China were once considered a major infectious disease, they appear to have dropped off China’s health “radar screen.”
Nearly half of all people living in developing countries are infected with intestinal worms. Intestinal worms can lead to poor health and poor nutrition, both of which can lead to poor educational outcomes (Bundy 1994, Del Rosso et al. 1996, Drake et al. 1999, Stoltzfus et al. 1997). Anemia, in turn, is often caused by intestinal worms that “steal” nutrients from food before the body can digest them. In addition to causing a variety of health problems, anemia has been shown to negatively affect educational outcomes by hindering cognitive ability and reducing attendance rates (Nokes et al. 1998).
Despite mass public health efforts during the 1950-60’s and 1980-90’s to eradicate intestinal parasites in China, helminth infection appear to remain a serious concern according to a number of studies (Wang et al. 2009; Hotez et al. 1997; Xu et al. 2000; Seto et al. 2008; Zhu et al. 2008). In a study of 1 million people by the Chinese Ministry of Health and Chinese Academy of Preventive Medicine, approximately half the population of the entire province have worm infections in some poor provinces (particularly the Yangtze river valley provinces such as Anhui, Hubei, Hunan, Jiangxi, Jiangsu, Sichuan, Yunnan (Hotez, 1997). As can be expected, the infection rates among the more vulnerable groups – such as children in poor, rural agricultural communities – are generally higher. Surprisingly, little is known about the exact determinants of worm infections. There are few disaggregated profiles, and even some reports that worm infection rates are currently low.
Importantly, in order to effectively prevent iron deficiency anemia to improve educational outcomes, a large-scale policy-relevant approach needs to be considered. A number of central questions still remain, including:
- Do the most effective options for prevention occurs at the household or institutional level? For example, successful intervention may involve parents and families, school administrators (principals, teachers, cafeteria managers), or some combination.
- Are liquidity or information constraints the key issues to be addressed? For example, it is unclear whether parents are aware that their children are anemic and even if they are aware, whether they have the economic means to regularly provide iron-rich foods. It is also unclear whether financial subsidies or incentives are an effective option for school principals to reduce anemia rates of their students by providing iron supplements (in tablet form or to be cooked directly into meals).
REAP Takes Action
A better understanding of nutritional deficiencies as well as worm infection in rural China is critical in order to address and mitigate the impacts of malnutrition on education. REAP is currently conducting a number of intervention studies in Northwest China as a multi-dimensional approach to achieve the following objectives:
- Document the prevalence of iron deficiency anemia and intestinal worm infection among school-aged children in rural China
- Understand potential impacts of iron deficiency on educational achievement and learning potential
- Identify and evaluate possible policy-relevant options for long-term solutions to address iron deficiency
REAP is currently focusing on these objectives in two implementation phases, which coincide with the school year calendar.
Phase I (2008-2009)
- Overcoming China's Anemia Puzzle in Poor Rural Elementary Schools: School Lunches, Nutrition Supplementation, Education or Deworming?
Phase II (2009-2010)
Our initial work on worms:
- Part I: Worm Count 2009: Deworming and Educational Performance
- Part II: Deworming and Educational Performance
A National Survey on Current Status of the Important Parasitic Diseases in Human Population（全国人体重要寄生虫病现状调查报告）, May 16,2005, Chinese Center for Disease Control and Prevention, Ministry of Health
Chen, Junshi, Xianfeng Zhao, Xin Zhang, Shian Yin, Jianhua Piao, Junshen Huo, Bo Yu, Ning Qu, Qiliang Lu, Shisun Wang, Chunming Chen. "Studies on the effectiveness of NaFeEDTA-fortified soy sauce in controlling iron deficiency: A population-based intervention trial" Food and Nutrition Bulletin, vol. 26, no.2 (2005)
Miguel, Edward and Michael Kremer. "Worms: Identifying Impacts on Education and Health in the Presence of Treatment Externalities"Econometrica, 2004, 72(1), 159-217
National Working Committee on Children and Women under the State Council（国务院妇女儿童工作委员会）
The Fourth Survey on Nutrition and Health of the Chinese Residents conducted in 2002 under the joint leadership of MoH, MoST, NBS.
Unpublished Study by Weiqing Wang, Associate Professor, School of Public Health, Xi'an Jiaotong University. [Randonly selected middle school in Shaanxi Province, 2007; N=422 1st year students: 37.7% anemia for the whole sample; 34.1% for the sub-sample of boys; 41.0% for the sub-sample of girls, most of whom are slightly anemic in a junior high school in rural Shaanxi.]