Fighting Child Malnutrition In
Africa Through The Use Of
Health Affairs June 2011
On a flat landscape of corn and tall
grasses sit groups of small square
huts, each constructed of mud
and dung and topped with either
thatched roofs or slabs of corrugated
metal. This is the village of Ahero, in the
Nyando district of southwestern Kenya, on the
shores of Lake Victoria.
In one of those huts, Peninah Achieng, a slim
woman in a loose blue and yellow plaid dress,
perches on the edge of a cushionless couch
frame. She looks to be about thirty, but she
doesn't know her exact age.
Her one year-old son, Willis, nurses at her breast,
while her youngest daughter, two-and-a-half year-old Liliane, sleeps on a chair. The girl does
not stir, even with four strangers in the room.
Chickens occasionally wander in and out of the
entrance. An antimalaria public service announcement
plays on the radio.
The four strangers are survey takers for
an international health organization and a journalist
who is accompanying them. At the moment,
Ms. Achieng is telling them that her son
has been eating dirt-four times in the last
Eating dirt is a compulsion common in the
children in this impoverished region of Kenya.
Pregnant women do the same thing; they actually
buy special cakes of chalky earth in the
market. The syndrome is known as geophagia,
or pica, and is associated with deficiencies of
iron and other micronutrients-commonly
known as vitamins and minerals.
Scenes from a hungry world: Nyanza, Kenya from Samuel Loewenberg on Vimeo.
That eating dirt is common in Nyando, a district
in Nyanza Province, is no surprise to the
visiting survey takers. They recognize it as a sign
of anemia, which affects two-thirds of children in
the area and an estimated four out of ten preschool
children in developing countries, according
to the World Health Organization (WHO).
Anemia and other ailments common to malnutrition
are the underlying cause of about onethird
of all children's deaths, says the WHO. Improving
child nutrition is a main thrust of the
United Nations' Millennium Development Goal
of reducing by two-thirds the mortality rate of
children under age five between 1990 and 2015.
As with other deficiencies associated with malnutrition,
anemia's initial symptoms are rarely
dramatic-small childrenwho are anemic mostly
lie listlessly about. In poor, remote areas like the
villages of Nyando, the condition is usually
ignored for the simple reason that without access
to medical care, and with better-quality food out
of reach for many of the world's poor, there's
usually nothing to be done.
But the consequences of this neglect are grave
because of childhood anemia's unsparing, longterm
effects: impaired mental and physical development,
and sometimes death.
Overcoming malnutrition once seemed insurmountable
in impoverished places like Nyando.
The region's largely uneducated population lives
on less than a dollar a day per person. The area
has little in the way of infrastructure for such
basics as clean water, electricity, and sewage,
and its poorly functioning health care system
can do little to correct the damage that such
poverty inflicts. Progress In A Packet
Sometimes, though, progress comes in unusual
guises. In this case, it took the form of a sandycolored
powder that comes in packets like those
containing sugar in American diners. The powder
is sprinkled onto food-hence its name,
Sprinkles contains micronutrients-vitamins
and minerals such as iron, zinc, folic acid, and
vitamins A and C-that the body needs, even if in
minuscule amounts. Micronutrients play a central
role in numerous essential body functions,
including metabolism, blood clotting, bone development,
the production of enzymes and hormones,
and nerve transmissions. They are essential
to healthy growth and development.
Sprinkles was created in 1997 by Stanley
Zlotkin, a University of Toronto scientist and
pediatrician at the forefront of efforts to curb
childhood iron-deficiency anemia. At that time,
anemia was considered the developing world's
“most common preventable nutritional problem
despite continued global goals for its control,”
according to an article that Zlotkin and his colleagues
published in 2005.1 It still is. Childhood
anemia in resource-poor settings has multiple
causes, including infestation with parasitic
worms, but one important cause is an irondeficient
From the beginning, global nutrition experts
believed that Sprinkles had the potential of sparing
millions of undernourished children from
anemia, provided that they ingested the product
regularly. A 1999 study of 557 anemic children
ages 6-18 months in rural Ghana showed that a
daily dose of Sprinkles was effective in treating
anemia without side effects.
Today, almost fifteen years after its development,
Sprinkles is manufactured in six facilities
worldwide and benefits more than four million
children in eighteen countries. It has been demonstrated
to be effective in reducing childhood
anemia in countries ranging from Bolivia to
The great innovation of Sprinkles, says Bruce Cogill, a consultant and the
former chief of nutrition at the US Agency for International Development
(USAID), is that it doesn't require recipients to eat unfamiliar food or
take a pill. They merely need to shake the product onto the food they already
eat, the way Westerners do with salt and pepper.
In 2007, Nyando, with its sixty villages and
total population of 80,000 people, seemed a
place very much in need of the benefits that
Sprinkles could bring. The level of childhood
anemia was 67 percent, and that of vitamin A
deficiency-the leading cause of preventable
childhood blindness and an underlying cause
of disease and death-was 18 percent. Dirt eating
“The mind [of people with anemia] says, 'Hey I
need iron,' so they eat dirt,” says Parmi Suchdev,
a nutrition expert at the US Centers for Disease
Control and Prevention (CDC) and the chief investigator
in the Sprinkles project in Nyando.
Suchdev, who is also a professor of pediatrics
at Emory University, believed in Sprinkles, but
he knew that having an effective product and
getting it to where it can do good are not the
same thing. As is often the case with new health
initiatives in the developing world, the challenge
would be figuring out howto distribute the nutritional
powder in Kenya in an effective and economical
But even that wouldn't be the end of it. There
was also the need to persuade parents to incorporate
Sprinkles into the diets of their children.
As many veteran aid workers knew from experience,
doing so would present a major challenge
in its own right. Efforts over the past decade to
broaden distribution of insecticide-treated bed
nets to combat malaria had amply demonstrated
that the simple availability of life-sustaining
products wasn't necessarily enough to guarantee
their successful use. Over the years, many insecticide-
treated nets had ended up being used as
fishing nets or dresses, or were used by the male
head of the family rather than by children and
pregnant women, who arguably needed
Suchdev was determined to find a way to avoid
a similar fate for Sprinkles. That's when he heard
about the “Avon ladies” of Nyando.
Avon Ladies In The Bush
Most Americans are familiar with Avon ladies-
women who sell products, sometimes door to
door, for the US cosmetic company Avon.
Nyando has an equivalent: a group of women
organized by a Kenyan nongovernmental
organization known as SWAP (the Safe Water
and AIDS Project). Instead of peddling facial
creams and nail polish, these women sell lowcost
public health products, including water purifiers,
condoms, and antimalarial bed nets.
SWAP was started in 2005 through support
from Rotary Atlanta and has since received funding
from the USAID, theWorld Bank, and others.
The organization has branched out from its
original focus on HIV/AIDS and clean water,
and it now has a solid track record of reaching
isolated communities and mobilizing people to
become engaged in their own health care. The
group has a well-developed network in Nyanza
Province, with more than 878 chapters in local
communities and roughly 6,000 vendors.
The strength of SWAP's sales force is that the
vendors aren't outsiders, but rather residents of
villages in areas like Nyando who have credibility
within their communities. The women not only
sell health products, but they also receive basic
training on how the products work, the causes of
diseases, and how to prevent them. They become
respected health advisers in their villages, who
preach the importance of such basic but essential
health practices as hand washing, sleeping
under bed nets, and drinking and cooking with
When nutrition experts at the CDC learned of
the existence of the SWAP ladies, they immediately
realized that they might have found the
solution to the problem of distributing Sprinkles.
“You have this 'Avon lady' with bed nets
and soap and so on,” Suchdev says, “and now
you're just adding a new product to her line.”
Suchdev worked with a veteran micronutrient
field specialist, Laird Ruth, to devise a protocol to
study the distribution of Sprinkles through
SWAP. Two qualitative researchers and a behavioral
scientist at the CDC created messages that
vendors would use to explain the product and
educate mothers about anemia.
The CDC also crafted promotional material
that vendors could hand out. A pricing structure
was devised so that the vendors would have an
incentive to sell Sprinkles. The cost to produce a
packet of Sprinkles was three Kenyan shillings
(about three American pennies), which was subsidized
by the CDC. Packets are sold to SWAP
vendors wholesale for one shilling each; the
vendors then sell each packet for two shillings
apiece and pocket one shilling per packet.
When Sprinkles was finally introduced, it was
backed up with a carefully designed marketing
campaign, which included skits performed in
local villages, testimonials from parents whose
children had used Sprinkles, and demonstrations
by vendors on how to use the product.
(Relying on reading material alone would not
have been effective because much of the region's
population is illiterate.) Marketing teams offered
incentives to both consumers and vendors,
such as T-shirts, stickers, calendars, and cups.
Even so, there were glitches. Initially, the nutritional
powder was met with skepticism or puzzlement
by residents of Nyando. Some people
tried to use it for soap.
The packets' red color also caused some consternation.
Aid workers quickly realized that
many villagers associated the color red with disease.
The color of the packets was switched to
blue. On the other hand, the fact that the packaging
looked foreign proved advantageous, says
Suchdev, because people didn't trust products
made in Kenya.
“I'm a doctor, not a marketing person,” he
says, but he admits that he learned a powerful
lesson about selling techniques. When popular
marketing incentives such as “buy one, get one
free” and promotional cups were later dropped,
sales of Sprinkles fell by more than half. “You
have to promote it like they promote Coca-Cola
and beer,” he says. “Expecting people to just take
it because it works isn't good enough.”
Suchdev also discovered how effective it was to
have vendors who lived in the communities
where they sold Sprinkles. An anecdote from
Nancy Auma Omolo, a thirty-two-year-old vendor
in the village of Kacholo, shows why.
Omolo says that some people in her village
asked her why the powder was only to be given
to children, not adults. “Do you want to get rid of
our children, or what?” they asked her.
A mother of six, Omolo says she would explain
that she had given the powder to her two smallest
children. Sure enough, she told them, those two
were soon much healthier and got sick less often
than her older children had. Once the village
parents began to see the effects of Sprinkles
on their own children, Omolo says, the supplements
became a big seller.
On market day in her village, Omolo hauls
bags of health items-antimalarial soap, water
filters, insecticide-treated bed nets, and Sprinkles-
to a large outdoor fair. She ambles among
the kiosks, chatting with the vendors, some of
whom have called to her by name.
She asks them about the health of their children,
and at their request hands over new packets
of the micronutrients or one of her other
items. She makes about 500 shillings ($5.75) a
week as a SWAP vendor.
Another vendor, Selina Achungu, a forty-twoyear-
old mother of three, has been selling SWAP
merchandise in the village of Kamahwa
Kasambula for nearly seven years. Like many
of the SWAP vendors, Achungu says she likes
her work because she feels she is helping her
community. And, of course, the money helps.
Selling SWAP merchandise, she says, supplements
her income from teaching preschool by
about 20 percent, or 200 shillings ($2.30)
Sprinkles, Achungu says, is one of her best
sellers, particularly after customers see its effect
on small children. She tells the story of a listless
two-year-old who was totally transformed after
only a few weeks of taking Sprinkles. “The child
could play [and] became active,” she says.
Studying The Impact Of Sprinkles
Built into the
Sprinkles project was a forty-threemonth, $1 million impact study, which
provided crucial information on what worked and what did not, and how much
of an impact the micronutrient powder was having in the community.
The evaluation included a detailed survey conducted
once a year for three years, plus monitoring
of the vendor training sessions, biweekly
monitoring of households receiving the nutrients,
and a continuing follow-up on how the
use of Sprinkles was affecting children's health.
The first year of the survey found that one out
of three families in Nyando used Sprinkles regularly-
higher than the one in five target that
Suchdev's team had hoped to reach. Levels of
iron-deficiency anemia fell by fourteen percentage
points and vitamin A deficiency by ten percentage
points. Approximately 53 percent of
children were cured of anemia.
More than a quarter-million packets were sold
in the study area between 2007 and 2009. And
dirt eating diminished.
In fact, the only complaint from mothers was
that the product may have worked too well,
Suchdev told an audience in August 2010 at
the Kenyan Medical Research Institute in
Kisumu, which is a coinvestigator on the project.
The mothers reported that Sprinkles not only
revived the health of the children, but that it also
made them hungry-a mixed blessing for poor
families, he noted. During the lean season in
between harvests, a hungry child is a burden.
That raised the dispiriting possibility that perhaps
Sprinkles should be distributed when food
is going to be available, after the harvest.
At any rate, now that Sprinkles has found a
market in Kenya, the next step is to convince a
Kenyan entrepreneur to manufacture the powder,
perhaps in partnership with a nongovernmental
organization. The Global Alliance for Improved
Nutrition (GAIN)-a Geneva-based
organization that is one of the funders of the
Sprinkles study-is working to do just that. At
present, the packets are produced and shipped in
from the Sprinkles Global Health Initiative-
approved factory in India.
The Sprinkles study had an unanticipated finding,
which appears to contradict a WHO recommendation
to cease using iron supplements in
areas with a high incidence of malaria. A 2006
study in Zanzibar found that for unknown reasons,
iron supplements appeared to increase the
severity of malaria infection in children, as measured
by an increase in hospitalizations. The
result of the WHO recommendation was that
millions of children stopped receiving iron supplements.
In contrast, in the Nyando study, the incidence
of hospitalization for malaria actually declined.
Suchdev postulates that the difference stems
from the fact that Sprinkles produces a slower
rate of absorption of iron, and at lower levels
than traditional iron supplements. The reason
is that Sprinkles is taken with food, as opposed to
the drops given out in the Zanzibar study, often
to children with empty stomachs. But the Sprinkles
study was not designed to test the issue of
any linkage between Sprinkles and the severity
of malaria infection. Suchdev says that a largerscale,
more focused study would need to be done
to fully understand the effects.
Independent of such issues, one conclusion that several nutrition experts
draw from the Nyando experiment is that the market-based nature of SWAP
largely explains its success as a distribution program. The lesson is critical,
because undertaking a successful health intervention is more than simply
handing out drugs, food, or mosquito nets.The goal is to have a longterm
impact, so distribution itself has to be durable and sustainable.
Dominic Schofield, a senior analyst at GAIN,
says that the approach is more sustainable than
would be the case if a governmental entity distributed
Sprinkles for free. It is also more likely
to help struggling working families in poor countries
whom government food or nutritional programs
often miss-because they are either too
poor to pay market prices for foods fortified with
nutrients or too “well off” to receive direct food
distributions from the government.
Sprinkles has served “the forgotten majority,”
says Schofield. So far, Suchdev and colleagues
have published four papers from the study,3-6
and a fifth, an overall analysis of the program,
was going through the CDC's approval process at
the time this article was published.
UNICEF, WHO, GAIN, and the government of Kenya have taken notice of the
findings of the Sprinkles/SWAP study and would like to replicate it in a
larger population, in either Kenya or other countries, according to Suchdev.
“We now need government and the private sector to take ownership of the
program and its formal implementation,” he says.
The exceptional amount of time and resources-
an estimated $1 million-that went into
evaluating and honing Sprinkles and the SWAP
community-based distribution program offer an
important lesson for public health. Even a seemingly
straightforward form of aid requires intense
scrutiny and oversight to get it right.
The distribution of micronutrients, rated by
the Copenhagen Consensus group of economists
as the single most effective public health intervention,
would seem far simpler than the complex
behavior change required for something as
complicated as controlling HIV/AIDS.Yet as the
Sprinkles study demonstrates, a straightforward
public health intervention such as giving out
micronutrients can be a complex undertaking.
What's more, such interventions can't overcome
all of the privations menacing impoverished
The Case Of Amos
Amos was one of five children
of Susan Atieno Onyango, who with her husband, a maize farmer, lives in
a mud and dung hut in the village of Scheme. The family income is about
25 shillings (29 cents) a day.
In 2010 Amos, then eleven months old, fell ill
with what his mother believed was malaria. Test
results showed that the child's blood had
extremely low hemoglobin, a sign of severe
anemia. The cause of the anemia was unknown;
given the region, it could have been due to infection
with malaria-causing or other parasites,
iron deficiency, malnutrition, an inherited blood
disorder, or a mix of several of these factors.
After suffering for several weeks, Amos died,
leaving behind his parents and siblings, including
Evans, an active three-year-old boy; Euphemia,
his four-year-old sister; and Vera, another
sister, age twelve. The youngest children, including
Amos, had been using Sprinkles. Mercifully,
all of the other children appeared to be healthy.
“Immediately after [starting on] the Sprinkles,
the kids had more blood in their bodies,” says
Atieno Onyango, showing her understanding of
the product's effects. “They became more lively.”
All except for Amos. His death is a sobering reminder that, as powerful
and important as interventions like Sprinkles are in addressing poor nutrition,
they are but one ingredient in the complex efforts that will be needed to
improve children's health in the world's poorest regions.