Caixin Column 2: China's Inequality Starts During the First 1,000 Days

REAP co-director Scott Rozelle builds on a ten-part series for Caixin Magazine titled, "Inequality 2030: Glimmering Hope in China in a Future Facing Extreme Despair." In his second column, Rozelle makes the case for meeting the nutritional needs of Chinese rural children in their first 1,000 days of life.


Inequality 2030:

Glimmering Hope in China in a Future Facing Extreme Despair 

Column 2: China’s Inequality Starts During the First 1,000 Days


The other day, I was walking through my Northern Beijing apartment complex when I came across a big sign posted in the courtyard: “Sign up now: get your baby into iMBA.” This was not an online course for the would-be business school student, nor was it an international business degree co-sponsored by a foreign MBA-partner school. The ad was for a high-priced day care for babies.

“You’ve got to be kidding me,” I thought, rolling my eyes. “Are you seriously going to teach your baby introductory courses in accounting, investments and human resource management?”

Fortunately, things are not that crazy, at least not yet. Further investigation revealed that the daycare strives to deliver care that will ensure the best start a child could have. Despite the unfortunate choice of name, the babies at iMBA are actually given fantastic care, meals and age-appropriate stimulation. (No Organizational Behavior for baby-beginners.) Lucky baby.

Of course, the care that these babies receive goes far beyond their daytime hours at iMBA. They are also dropped off in the morning and picked up at night by loving parents who spend a large fraction of their waking hours researching, purchasing, and preparing nutrient-rich meals for their child. Baby gets a bedtime story every night, has a bedroom filled with educational toys, and is already learning how to sing traditional children’s songs. Again: Lucky baby. Healthy. Happy. Well on his way to taking the gaokao, going on to college, and enjoying the good life in Beijing.  

Now let’s go to 1500 kilometers away, to the mountains of Central China. Our organization, the Rural Education Action Program (REAP), is finding that babies are growing up very differently here compared to Beijing. And this stark contrast does not bode well for China 2030.

Let’s first take a look at the REAP study. Our team—made up of economists from Xibei University of Xi’an, econometricians from the Chinese Academy of Sciences, and doctors and nurses from Sichuan University’s School of Public Health—wanted to be able to characterize the nutritional environment in which over half of China’s future population is growing up. To do so, in April, 2013 we randomly selected 2000 families with babies to participate in our study. In total our team of nurses visited over 350 villages in 11 mountainous, rural counties, testing mothers’ and babies’ nutritional status. These are not remote minority communities. Most of the villages can be reached from Xi’an within 3 to 4 hours. All of the families are Han. You may have seen Dad working on the construction sites in Xi’an. Mom was your housekeeper before she went back home to give birth, and she will probably be back at her post as soon as her baby is 6 to 12 months old, leaving Grandma in charge of baby duty. There are tens of millions of families across China just like the ones in our study.

So what did we find? In China today—in the same China where babies in Beijing are attending fancy daycares like iMBA—more than 1000 of the 2000 babies we tested were malnourished: 55.7 percent to be exact. When we added in those who were borderline anemic, we found that over 80 percent of the babies we tested were malnourished.

In a nutshell, this means that more than half of the babies in rural China are sick.

Of course, sick babies will get better, won’t they? If a baby is malnourished, won’t she be okay after she starts a better diet? Sure maybe kids in rural schools are skinnier and shorter than kids in city schools, but they eventually grow out of being sick, right? What are the long-term consequences for children who are micronutrient deficient as babies?

In fact, studies increasingly point to the importance of meeting the nutritional needs of children in their first 1,000 days of life, from conception to 2 years of age. The effects of inadequate nutrition in this brief window are long-term and irreversible. Babies who are malnourished as babies grow up to have lower levels of educational attainment, lower lifetime earnings, and higher rates of criminal activity. And, more importantly, these effects are permanent. After the first 1000 days, nothing can be done to repair the damage. It does not matter how much care children receive after their second birthday: the damage is already done. For this reason the treatment and prevention of micronutrient deficiencies during this critical time period is an investment not only in the present, but in the future.

With this important connection between nutrition and cognition in mind, REAP embarked on the second part of our study: measuring the cognitive development of the babies in our rural counties. We trained a small group of graduate students and post-docs in the skill and art of administering the Bayley Scales of Infant Development (or the Bayley test for short). The Bayley test is an internationally scaled test of baby and toddler development. We used the Chinese version of this well-respected and frequently used test to measure the cognitive and motor development of all of the babies in our study areas.

What did we find this time? More bad news: More than 70 percent of the babies were significantly delayed in either their cognitive or motor development. Instead of heading towards a bright future, they are on track to fall far short of their potential. By the time you read this column, this cohort of babies will only have about 12 months left before their 1000-day clock runs out. If nothing is done before then, they will be relegated to a lifetime of underperformance: lower grades in school, worse job outcomes, and lower incomes. 

How can we help these babies? Before we can answer that question, we have to ask another one: What is the underlying cause of rural China’s malnutrition problem?

Is it possible that poverty is the main reason for this epidemic of malnutrition? Maybe, but we don’t think so. At least, for most families this is not the primary reason. In today’s China, especially in poor, predominantly Han areas, most families have one or two members in the off-farm labor force who send the better part of their salaries back to the village. Families also receive agricultural subsidies and “Grain for Green” payments. There are programs that help them pay for visits to the hospital, for school fees, and for supporting their elderly parents. In fact, these families are rich enough that the caregivers themselves are well-nourished and well-cared for. While over 80 percent of babies are malnourished, only around 25 percent of mothers are. 

Rather than simply blaming poverty, then, we think that the basic reason for such high rates of malnutrition and delayed development is an absence of information. Parents and grandparents simply do not know how to provide a healthy diet and a stimulating environment for their babies. Mothers aren’t taught about nutrition or parenting in school or during their prenatal visits (if they even had a prenatal visit). Grandmothers learned to raise babies in another era. Grandma raised her sons and daughters to be good farmers. She didn’t worry about whether her children had the human capital to make it through high school math, science, computers and English.

We have evidence to back up this conjecture. At the same time that we tested babies and mothers for anemia, we also asked babies’ caregivers two sets of questions that were designed to test their nutritional know-how: one set of questions about baby nutrition….and one set about pig nutrition. Shockingly, caregivers demonstrated that they knew more about raising healthy pigs than about raising healthy babies. For example, nearly 70 percent of caregivers stated that piglets required sufficient levels of micronutrients to grow up to be a healthy (and profitable) pig. In sad contrast, caregivers knew pitifully little about how to raise a healthy baby. Fewer than one-third of caregivers thought that micronutrients had anything to do with babies’ healthy development. As one grandmother said: “All babies need to be healthy is rice porridge. It was good enough for me, it was good enough for my children. They are just babies after all!” This ignorance about how to raise babies is putting an entire generation at risk. If one-quarter to one-third of China’s babies are malnourished and cognitively delayed, this means that one-third of China’s future labor force will be cognitively delayed. Hundreds of millions of Chinese children are not getting the skills they need to be productive members of China’s economy and society. Inequality 2030—perhaps more than anything—will be shaped by inequalities in the way babies are raised today. Things are not going well.


So, back to the main question: what can we do about this problem? Lu Mai is the director of one of the most influential think tanks in China today. Last year, his group, the China Development Research Foundation (CDRF), rolled out an innovative pilot program in Qinghai Province. Caregivers were given nutritional training and access to a simple and effective package of vitamins and minerals, Yingyangbao. This is basically a multivitamin for babies. Caregivers simply mix a daily dose of Yingyangbao into their baby’s water, formula, or porridge, and baby immediately gets 100% of her daily needs of more than 15 essential vitamins and minerals. The Heinz Foundation and their partners in the Ministry of Health system conducted a similar intervention. In both of these study sites the babies’ nutritional outcomes significantly improved. Lu Mai’s amazing policy communication skills have helped push this program onto the national agenda. The national Ministry of Health has committed to giving out Yingyangbao in 100 counties to see if CDRF’s results can be upscaled to increase the health and nutrition not just of thousands, but of millions of babies. If the program can be effectively rolled out and implemented, the effects could drastically improve the lifetime health, happiness and prospects of an entire generation of rural Chinese children. I vote for Lu Mai to be given the Nobel Peace Prize.

So are we done? Have we saved China’s future generations? We at REAP believe that while the objectives of the Yingyangbao program are spot-on and vitally important, the effectiveness of the current policy implementation plan is still unclear. We have seen several of the pilot sites in a number of these 100 experimental counties. To be brutally honest, things are not going well. CDRF was very careful with project design, monitoring and administration. The top leadership of the province was fully behind that initial project. And it worked. Brilliantly. That level of careful implementation, however, is not being repeated in this second wave of experimental counties. This time around, caregivers are rarely given any training. Convincing cautious caregivers that they should feed baby something new—something that looks like medicine—is not a trivial task. Training is a necessary step. This time around, caregivers often have to pick up their monthly supply of Yingyangbao themselves from a central location, sometimes several hours away from their home. Moreover, many parents (more than half) are leaving the village and choosing to raise their babies in nearby towns, county seats or provincial cities where Yingyangbao programs are not available. If you make caregivers travel long distances to pick up the nutrition packets, many don’t—especially when they have been given little reason to believe it will really help their babies. Above all, the second-wave program has little follow up. There has been no systematic evaluation to find out if this upscaling of the CDRF’s original experiment is working. If it is not working, there is no effort being made to find out why not.

But don’t worry, we haven’t given up yet. REAP is working on a large-scale pilot project that we hope can help identify more effective ways of delivering Yingyangbao—and better health, nutrition, and cognitive performance—to babies across China. To do so, we are working with the National Family Planning and Population Commission (now part of the Ministry of Health) to deliver Yingyangbao directly to households, so caregivers can give babies what they need without even having to leave the house. Our partners at Xibei University, Xi’an Jiaotong University’s School of Medicine, and Sichuan University’s School of Public Health have developed caregiver-friendly training materials. We spend time with caregivers and come back repeatedly to answer their questions and encourage them to stick with the program: one packet of Yingyangbao per baby per day.

And, perhaps most innovative (and effective), we have teamed up with China Mobile to roll out a text messaging program in a randomly selected subset of villages. Each morning, at the start of baby’s day, we send out a text message to all caregivers urging them to feed baby her Yingyangbao. We remind Mom. We encourage Grandma. REAP and our partners are showing that by using modern mobile technology we can increase Yingyangbao use and decrease program dropout.

And in all of these programs, our emphasis is on results. At every step of the process we are carefully evaluating what works and what doesn’t so that we can help to develop a policy implementation plan that can truly reach every baby in rural China.

If anyone believes overcoming malnutrition in China over the next five to ten years is going to be easy, we tell you right now: you are dead wrong. It is very difficult. There are many obstacles. But, with an organization like the National Family Planning and Population Commission and their network of staff (and their bold leadership), and with the hard work and dedication of all of our other partners, we believe we can overcome these hurdles.

China’s number one challenge might very well be this one: Ensuring that all babies are healthy, smart, and ready for life in the 21st century. If we fail now, we will have huge inequality in preschool, huge inequality in elementary school and huge inequality in junior high and high school. And looming on the horizon is the ever-present danger of Inequality 2030, . Each day that we fail to act is the one-thousandth day for another baby, so the time for action is today.

Thank you to all of our collaborators on this project, especially Professor Yaojiang Shi from Northwest University, Professor Renfu Luo from Chinese Academy of Sciences, and Professor Zhou Huan from Sichuan University. This project would still be a lonely piece of paper sitting on a desk if not for the countless hours that they have spent in the field interviewing families, coordinating with local contacts, and training the survey teams. Nimen xinkule.

To read the column in Chinese, click here.

About this series:

REAP co-directors Scott Rozelle and Linxiu Zhang are writing a ten-part series for Caixin Magazine titled, "Inequality 2030: Glimmering Hope in China in a Future Facing Extreme Despair." See below for more columns in this series:

> Column 1: Why We Need to Worry About Inequality

> Column 2: China's Inequality Starts During the First 1,000 Days

> Column 3: Behind Before They Start - The Preschool Years (Part 1)

> Column 4: Behind Before They Start - The Preschool Years (Part 2) 

> Column 5: How to Cure China's Largest Epidemic

Column 6: A Tale of Two Travesties

>Columns 7 & 8: China's Widest Divide

> Column 9: China's Most Vulnerable Children

> Column 10: Why Drop Out?

> Column 11: The Problem with Vocational Education

> Column 12: Reforming China's Vocational Schools (in Chinese)