Caixin Column 5: How to Cure China’s Largest Epidemic


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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 fifth column, Rozelle explains how China's "National Nutritious School Lunch Program" became a National Free But-Not-Too-Nutritious School Lunch Program.

To read the column in Chinese, click here.


Inequality 2030:

Glimmering Hope in China in a Future Facing Extreme Despair 

Caixin Column 5: How to Cure China’s Largest Epidemic


What do we know about China’s largest epidemic?

  • We know that 10 million school-aged children in rural China are suffering from iron-deficiency anemia and generally poor nutrition.
  • We know that poor nutrition is undermining their education.
  • We know that poor nutrition is the first barrier contributing to the performance gap between rural and urban students—one that does not disappear.
  • We know how to solve poor nutrition: with one multivitamin a day, costing only 0.2 yuan. Or with an 8 yuan per day nutritious school lunch.
  • We know that one vitamin per day – or a nutritious school lunch – will raise the students’ educational performance, turning a student who is failing into one who earns passing, satisfactory test scores.

We know all of this already. It is clear and proven. Our group, the Rural Education Action Project, or REAP, has run no fewer than five studies on the link between nutrition and education. These have been large, well-designed, carefully implemented studies with some of China’s best academic institutions and medical schools involved. The results have been consistent and clear.

Nutrition-related diseases are epidemic. We found nearly 40 percent of grade 4 and 5 students in Shaanxi to be suffering from anemia. Another study in Qinghai found nearly 50 percent of students to be nutritionally deprived and sick. The same is true in Gansu, Ningxia, Sichuan and Guizhou. In any random rural community in China, it is a near guarantee that you will find thousands of undernourished children. Convert these percentages into absolute numbers and the numbers are staggering.

We also know that the diets of children in China’s rural communities are the source of the malnutrition problem. Parents and grandparents (when Mom and Dad are away from home working) and boarding school managers (when kids live at school) are feeding students insufficient diets. Despite rapidly rising family incomes, the typical meal for rural students—both at home and at school—resembles meals that rural children were eating decades ago: grain, grain, more grain, and a tiny bit of pickled vegetables. There is almost no meat, there is almost no fruit, and often there are almost no fresh vegetables. 

It is a well-established fact that when children eat meals like this, they become nutritionally deprived. They are iron deficient. They do not have sufficient vitamins and other minerals. And, despite having no clear outward symptoms, they are sick. Anemia is a disease. It is a well-known and well-understood disease that leads to stunting and wasting, poor general health, and even reduces children’s cognitive abilities. It should therefore come as no surprise that in our studies, we find that children with anemia are shorter, lighter, miss more school due to illnesses, and have overall worse school performance than their non-anemic classmates. This is most likely one of the reasons that China’s tremendous investment into new rural school facilities and teachers has failed to produce any reduction in the rural-urban education gap. When children are sick, they can’t learn, no matter how good the school is. Enroll a malnourished 10-year-old in the best school in China—say Remin University’s Attached Elementary School—and despite the best teachers and best facilities, that child will not learn. That child can’t. Because that child is sick.

We know, however, that if we improve nutrition, the negative effects of poor nutrition can be reversed and children can learn and perform better at school.

In 2007, Lu Mai and his group at China Development Research Foundation, or CDRF, demonstrated the power of nutrition in a set of pilot schools in rural China. It was a simple and elegant demonstration. When children were given good nutrition, within months they were performing at a much higher level in school. This was the key breakthrough that inspired our group’s main research agenda between 2008 and 2012. 

REAP’s first school nutrition project launched in 2008, in Shaanxi Province. We gave children in 30 schools one vitamin per day for one academic year, and saw their standardized test scores rise much more than children in 30 similar schools that did not receive a daily vitamin. The impact of the vitamin intervention was even higher when children were also given a daily egg on top of the vitamin. In 2009, we showed that the test scores of children who received both a daily vitamin and a daily egg rose much higher than children who just received a daily egg. In fact, in 2010 we showed that a daily egg by itself is not enough to have any impact on children’s health or academic performance: When we gave children in 25 schools an egg a day for one academic year, there was no reduction in anemia rates and test scores did not improve.

But eggs are a nutritious food, aren’t they? Why aren’t they helping China’s school children? The answer is simple: The problem in rural China is micronutrient deficiencies, especially iron deficiency, which leads to anemia. Eggs are definitely not bad for children, but they do not have iron. Vitamins do. Our research has convinced us that vitamins are the fastest and most cost-efficient way of getting iron (and other key nutrients) to China’s rural school children.

Finally, in 2010 and 2011, we showed that when principals are incentivized and provided with the resources to give students healthy, nutritious meals (two dishes with meat and fresh vegetables per day), nutrition also improves, along with educational performance. A truly nutritious school lunch is more expensive than a vitamin (8 yuan versus 0.2 yuan per day), but nutritious lunches have been shown to be successful in improving health, nutrition and ultimately test scores.

The Good News: Policy Makers Respond

As the link between nutrition and education began to become clear, policy makers responded. Top leaders began to take notice.

REAP’s work initially generated a response from leaders in Shaanxi Province, where we had conducted many of our nutrition projects. In 2009, several counties in Southern Shaanxi joined together to pilot a regional experiment that improved nutrition in schools. The entire province followed suit the very next school year. The goal of the program was to improve the nutrition of every child in every rural school—from grade 1 to grade 9. National leaders became aware of REAP’s findings and of the positive impact of nutrition on educational performance.

The media provided the final nudge. Throughout 2011, news outlets and child-welfare groups published articles and reports about the abysmal state of nutrition in rural China’s schools. The coverage garnered the interest and attention of millions of netizens.

In October, 2011, the national government made a bold move. They announced a new annual commitment of 20 billion yuan per year to fund a new National Nutritious School Lunch Program. The new program would provide over 25 million school-aged children in 692 poor counties with a nutritious school lunch per day. The stated goal was to improve nutrition, health and ultimately increase the educational performance of rural students.

This was the ultimate victory for an effort that began with scholars, was picked up by the media, and finally acted upon by the central government. There is a problem; it is affecting progress towards China’s developmental goals. There are solutions; allocate the resources and put the programs into place.

This is exactly how academics, the media and the government are supposed to work together. Right?

The Bad News: Policy Failure and China’s Remaining Nutrition Challenge

So has the problem been solved? Unfortunately, the answer is no. According to REAP survey data from 2012 and 2013, malnutrition is still widespread and children are still not receiving healthy meals either at home or at school. 

What happened? The national government’s “National Nutritious School Lunch Program” failed because there were simply not enough resources. Not enough school kitchens. Not enough financial resources. Not enough buy in from local governments. 

The original plan was this: The national government would allocate 3 yuan per day per student to help finance a nutritious school lunch. In Beijing, nutritious school lunches provide about half of each student’s recommended daily allowance (RDA) of key vitamins and minerals, including more than half of each student’s daily iron needs. This is just about perfect: dieticians in school systems around the world agree that school lunches should provide at least 40% of a child’s RDA.

Three yuan, however, did not get the job done. Three yuan in today’s market was only enough to give children a large bowl of rice (or large bowl of noodles) and some pickled vegetables. In other words, it was just enough to replace exactly what children were bringing from home to eat—before the launching of the National Nutritious School Lunch Program. Children could now get their school lunch for free. But they were not getting anything better or more nutritious than what they would have brought from home anyway. In effect, the National Nutritious School Lunch Program became a National Free But-Not-Too-Nutritious School Lunch Program.

Indeed, our research shows that the policy has failed to provide the nutrition that children need to do well in school. REAP followed schools both before and after the launch of the national program. The nutritional content of the lunches provided by the schools was almost unchanged. It is therefore unsurprising that there was no impact on reducing anemia, improving health or improving educational performance. 

Several problems led to this policy failure. First, and foremost, even though the national government asks local governments to contribute matching funds to improve school lunches, they rarely do. Poor counties are chronically short of fiscal resources. This is a mandate that they were simply unable to achieve. Even if they did, however, six yuan is still not enough for a nutritious school lunch. It would be better—of course. However, our team’s calculations indicate that it would take eight to nine yuan per student per day to be able to offer a high quality, nutritious meal. The national government was bold to take on the challenge of providing nutrition for school children in rural China. It is clear, however, that they need to be even bolder. The program as currently designed is simply acting as an income transfer to parents; the national funding is offsetting what parents used to provide. Children, however, are getting the same food and are still malnourished. 

Second, the program, as designed, leaves the responsibility for providing lunches to the local government. Most local governments further pass this responsibility on to individual school principals. Are principals qualified to take charge of this sort of policy implementation? Rural school principals are not trained in nutrition; in fact, we find that principals understand little more about nutrition than the parents of their students. Moreover, principals face other incentives that dampen their willingness to spend time and resources on nutrition. In other countries, and in China’s urban school districts, there are nutritionists, dieticians and catering firms that take on responsibilities for serving quality, safe and nutritious meals. In such settings principals are able to focus on doing what they are trained to do: manage teaching, meet with parents, ensure a safe school environment, and take care of other general school management needs.

What’s next?

We know the problem. We know the solution. Leaders have shown that they are willing to try to solve the problem. Solutions have already been tried. They are not working. But they can form the basis of what to do next.

We need to make the National Nutritious School Lunch Program nutritious. There are three different possible ways to do so. One option is for the national government to immediately increase allocations for the National Nutritious School Lunch Program to eight yuan per student per day. This is admittedly not a small sum. But, it is needed, and needed now. Proper school infrastructure for clean kitchens and a trained staff are also needed. This will not only improve meal quality, it will reduce stress on principals and allow them to focus more on their main job of running the school.

There is a lower cost solution. It is one that is used in many countries, and has also been repeatedly proven to work in China. The solution is this: use part of the National Nutritious School Lunch Program funding to provide each student with one vitamin per day. A high quality multivitamin with iron can be purchased and distributed for 0.1 to 0.2 yuan per day. It is easily monitored. No additional facilities are needed. It is true (and we are not arguing otherwise) that children cannot survive on a daily vitamin alone. But, it is a safe and effective way to deliver iron and other minerals, a lack of which we already know leads to worse educational performance. Moreover, spending 0.2 yuan per student per day on a multivitamin still leaves 2.8 yuan of national funds leftover. China’s officials need to be convinced that vitamins are not medicine. They are safe. They are inexpensive. They are effective.

Of course, the third option is that both of these solutions be implemented, to create an ultra-nutritious national lunch program. If we choose to go this route, China’s nutrition problems would soon be a relic of the past. Then we could finally begin to take advantage of the new facilities and better teachers. And we could take the first step towards closing the rural-urban gap in education.

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)