Kokopo, East New Britain.
Amidst yapping dogs and swaying palms, the nervous young mother sits at the sturdy table set up in the dusty yard of her village.
Local health workers Pele Melepia and Priscah Hezericlad stretch out her one-year-old baby girl and measure her length with a contraption that resembles those used to measure foot size. The baby is also weighed carefully on a set of digital plastic scales.
Next it is the mother’s turn. Cleared of the clunky devices, the table is quickly transformed into a state-of-the-art pathology lab. Atop a sterile blue paper cloth appears a small blue box, two white strips of filter paper and a small graduated glass rod. A large drop of blood ebbing from the mother’s pricked finger will reveal whether she is anaemic or carries malaria parasites. A vaginal swab, which she has discretely provided, will take stock of any genital tract infections.
The entire exercise has taken the four-member team – also comprising Primrose Homiehombo, who interviewed the mother, and Dukduk Kabiu, the community liaison officer – half a day. The potholed three-kilometre dirt track that leads to the village situated within the Tokua plantation is one reason. Waiting for the mother to return from an excursion is another.
It’s not unusual. For the last two years the dedicated Papua New Guinean (PNG) staff of the Melbourne-based Burnet Institute have repeated this exercise thousands of times to track down mothers and babies in remote villages across the province of East New Britain (ENB). Populated by some 400,000 people, the island is a microcosm of the mainland, nestled to the south-west. Villages are isolated by rugged terrain and accessing them is often a one-to-two-day journey down potholed dirt tracks and across footbridges, carrying equipment and ice buckets to keep tissue samples cold.
Their dedication stems from a conviction that the measurements and tissue samples they are gathering will help solve one of PNG’s most pressing health problems: the poor growth and development of its children, commonly known as ‘stunting’.
“We need this data to advise our politicians”, Essie Koniel tells me. A handsome, middle-aged woman from a tiny fishing village in the north-west of the island, she’s the Burnet Country Operations Manager for the 40-strong team at the Institute’s headquarters in Kokopo, which has been the ENB capital since volcanic eruptions destroyed Rabaul in 1994.
“This data is like gold”, agrees Brendan Crabb, the Burnet Institute’s Director. “We’ll never have to repeat this study and it won’t just help the people of PNG; it will help poor communities all over the world,” he tells the people at the village in Tokua plantation via liaison officer Dukduk Kabiu.
Crabb is making one of his regular visits to Kokopo, accompanied by his partner – paediatrician Michelle Scoullar – deputy director and public health physician James Beeson, midwifery professor Caroline Homer, paediatrician Chris Morgan and me – a journalist and donor to the program.
Globally, children in poor countries experience stunting rates of about 22%, but PNG stands out with around 45% of its children falling well below the normal range for height by the age of two. It doesn’t just mean these children will be short; they are more likely to be sickly throughout life, and less likely to reach their full intellectual potential.
It’s not a statistic that sits nicely with Prime Minister Peter O’Neill’s modernisation narrative.
There’s no doubt the country’s public health system is struggling. The polio outbreak last June put PNG on the global radar but any number of indicators bear testament: chronic malaria, drug resistant TB and the fact that PNG women are 35 times more likely to die in childbirth than their sisters across the Torres Strait.
Nevertheless, stunting stands out as a problem of special urgency. The World Bank President, Jim Yong Kim, has highlighted stunting as “a humanitarian disaster”. The World Health Organization (WHO) ranks it as a number one priority for development – and with good reason. The prospect that a fifth – or in the case of PNG, half – of the population is starting life behind the eight ball is a dismal basis for nation-building. “People will be left behind,” says Crabb.
While it’s clear that modernisation and rising affluence largely eradicate the problem of stunting, in PNG that’s a slow process hindered by rugged terrain, earthquakes, tsunamis and erupting volcanos. For Crabb, the question is “What can you do while waiting for the country to modernise?”
That’s why three years ago, the Burnet in collaboration with the PNG Institute for Medical Research, the University of PNG and government partners, embarked on the landmark “Health Mothers, Healthy Babies” (HMHB) study to winkle out some answers.
Now, as the final data comes rolling in, the combined teams are starting to find answers and, ever so carefully, consult with community partners to plan the first intervention trials.
So, what exactly is stunting?
A child is defined as stunted when they are exceedingly short for their age. In formal terms, it’s when they fall two standard deviations below a global average.
As a metric, it’s not without its controversies. But according to Mercedes de Onis, the coordinator of the WHO’s Growth Assessment and Surveillance Unit, “it is the best overall indicator of children’s well‐being and an accurate reflection of social inequalities”.
“It’s understood to be a response to chronic malnutrition”, says Beverly Ann Biggs, a public health physician at the University of Melbourne who researches stunting in Vietnamese and Australian Aboriginal communities.
If it persists beyond the age of two or three it’s mostly irreversible. “The body’s metabolism decides this is all I’m ever going to get and adjusts overall body size”, explains Morgan.
By contrast, ‘wasting’, another metric of nutrition often measured by a thin mid-arm circumference, is usually a response to an acute illness like diarrhoea and is quickly reversed by feeding.
Chronic malnutrition often begins in the womb with the foetus receiving insufficient nutrients across the placenta. That in turn appears to be linked to the mother’s nutrition even before she becomes pregnant, as well as to the diseases she carries.
Besides losing height, stunted children are at significantly higher risk of infections in childhood and chronic diseases such as diabetes in later life. However, the main game, says Morgan, is the impact on the brain. It’s an energy hungry organ and stunting compromises its development. “It means not as clever, less likely to finish school, less likely to hold a good job, or even to stay out of gaol.”
The World Bank’s Kim puts it more bluntly: “Inequality is baked into the brains of 25% of all children before the age of five.”
If stunting is a problem of malnutrition, why then not just ramp up the nutrition for mothers and babies? Why is the costly HMHB study necessary at all? It’s a question I seem to ask the researchers over and over again during my four-day visit. After all, as I say to the endlessly patient, soft-spoken Beeson, this is not rocket science.
“It’s harder than rocket science,” is his riposte. “It’s not just about understanding the medical causes. You have to get interventions out to remote communities, build relationships and acceptability and educate and engage communities.”
And no-one seems to believe that an intensive feeding program – a roll-out of enriched protein biscuits, as I suggest – is the answer. Morgan points out that past interventions of this type have delivered little benefit. Crabb is dubious that nutrition, as far as calorie intake, is the major problem here. Measurements of mid-upper arm circumference show that most women are receiving sufficient food, though that still leaves open the possibility that micronutrients are missing, says Beeson.
Surprisingly, all believe that the medical causes of stunting are poorly understood. Beeson points me to a recent paper that identified 18 risk factors in 137 developing countries.
The top five are: foetal growth restriction (so the baby is small for its time in the womb), unimproved sanitation, child nutrition, infections and indoor pollution resulting from the use of low-quality cooking fuels such as firewood or crop residue. But the paper acknowledges that the relative impact of such factors differs from country to country. “It is also the interaction between factors, for instance, between food and infection, that is likely to be crucial, but is not well studied,” says Morgan.
Biggs agrees: “It’s complicated; that’s where the HMHB study comes in.”
In the case of PNG, the researchers suspect the major contributors to stunting are likely to be malaria in pregnancy, which interferes with the formation of the placental blood vessels that nourish the growing foetus; intestinal infections that cause chronic inflammation and prevent the mother and child from absorbing nutrients; and deficiencies of micronutrients like zinc, iodine, vitamin A and specific amino acids. But for the cautious Burnet team, suspicions are not enough. “We decided to do something other than guess,” says Crabb.
Indeed, recent studies show that rolling out interventions based on ‘best guesses’ is risky. Last January, a Stanford University-led trial that went by the acronym of WASH found that improving sanitation in the households of 5000 pregnant Bangladeshi women was successful at reducing rates of diarrhoea and deaths. But it did not result in increases in the linear growth of the children in their first two years.
Another study recently published by the Burnet researchers showed that contrary to assumptions, women who were iron deficient actually gave birth to larger babies.
Administrators are also in no mood for rolling out costly interventions based on best guesses. At a meeting in the Kokopo provincial office, Nicholas Larme, the deputy provincial administrator, captures the current appetite for evidence when he says, “I’m a great believer in research. Malaria [for instance] has been here forever; what is it we can do differently?”
The HMHB aims to provide some answers. In labs in PNG and Melbourne, researchers have been “science-ing the shit” out of tissue samples collected from 700 mothers and babies. Are they riddled with malaria, TB or other infections? Do they bear the chemical markers of chronic intestinal inflammation? What are the blood levels of essential minerals, vitamins and amino acids? Meanwhile, questionnaires have taken stock of how well current medical advice is being implemented. For instance, breast feeding provides the best nutrition for babies, but are the mothers breast feeding for the recommended time? How often do they visit the clinics after giving birth? Are they completing their infant’s vaccination schedules?
If Beeson and Crabb are the architects of the HMHB project, it was Scoullar who built it brick by brick.
What started out as a short-term project has become her life. When she arrived in Kokopo in 2013, she was a newly divorced 30-something. Five years later, with the project nearing completion, she is partnered with Crabb, a slim, dynamic 50-something and the mother of their bright, bonny one-year-old twin girls. Clearly the HMHB project has been an intensely personal journey for both.
A visit to a birth clinic perched atop a lush hill on the outskirts of Kokopo brings this home. Though the clinic wins praise as one of the best equipped on the island, thanks in part to Scoullar’s efforts, when we visit it is the scene of a recent tragedy. During the night Jennifer, the midwife, delivered twins but the second twin lodged shoulder first and died before he could be delivered. Homer, a calm, kindly woman who has contributed to midwife training programs throughout PNG, commiserated. She tells Jennifer it was a very tough call and that she would not have managed any better, and she praises her administration of the drugs misoprostol and oxytocin to prevent the mother from haemorrhaging.
Scoullar and Crabb were clearly affected. “All that growth for nothing,” Crabb murmurs to me. The dead twin had weighed nearly 3.5 kilograms. His own twin girls barely reached three kilograms at birth. The comparison could not have been starker. Two mothers giving birth in countries barely an hour’s flight in distance – yet worlds apart.
Scoullar is a gentle, intense young woman with gritty determination. She has a natural feel for how to operate in PNG, balancing cultural sensitivities with science and a knowhow of how to operate in the heat, amidst earthquakes, volcanic eruptions and fractious national politics, and with limited infrastructure.
No doubt her childhood in Tonga, Sri Lanka, Nigeria, Zimbabwe and Pakistan – her father worked in agricultural aid – equipped her with some useful skills. Her teenage years living in her mother’s small NSW country town might also explain her easy, convivial manner. “I was related to one in four people,” she recalls.
It took all her skills to execute the HMHB plan. It was simple enough on paper: 700 women – a statistically robust number – to be recruited from five antenatal clinics across ENB, with follow ups at birth, one month, six months and 12 months.
But the implementation was tough: finding buildings, equipment, skilled employees, designing effective questionaries – not to mention the logistics of turning dusty village yards into sterile labs.
“We had to remember every single thing: blueys [sterile blue sheets], sterile gloves, non-prick needles, zip-lock bags, eskies, shade, privacy screens, tables and chairs, a sturdy space to weigh and measure babies”. It was “a stressful time but the best time”.
Sandra Lau, a generous local businesswoman, and Nicholas Larme, then the local health officer, were instrumental in helping her locate the former concrete block restaurant that now serves as the Burnet Institute Kokopo administrative centre, and a room at St Mary’s hospital that serves as a state-of-the-art pathology lab, headed by the conscientious Ruth Fidelis. Their whirring PCR machines rapidly analyse the DNA of microbial samples. Back-up batteries are crucial for keeping samples frozen, as the electricity regularly goes on the blink. Dukduk doubles up as an able lab technician. The one-time bank manager was recruited as a driver, but Scoullar quickly observed that he was capable of much more.
There are many stars amongst the PNG staff, including those who gather samples from the mothers and babies in villages and birth centres, lab workers, administrators and doctors. Their sense of purpose is palpable. It’s a testament to the Burnet mission: not so much to carry out research as to equip the people of PNG to do their own.
“If they don’t own the research, they don’t own the findings and the solution won’t work in the long-term,” explains Beeson.
It’s a hard-earned wisdom. The history of public health is littered with fixes that have been rolled out only to fail. Many of the Burnet team have seen the failures firsthand. Beeson’s hard-earned experience comes from working in Malawi, where he pioneered studies showing how malaria infects the placenta of a pregnant woman and can compromise nutrition to the growing foetus.
Morgan spent decades rolling out vaccination programs throughout Asia and Africa before shifting focus to iron out glitches in health systems. His connection to PNG came early, attending school there in the 1960s while his father taught in teachers’ colleges, then returning after medical training to work as a doctor on and off since the 1980s.
Crabb himself is not clinically trained. His life’s work has centred around laboratory-based malaria research, specifically attempts to develop a vaccine. But he too has a particular connection to PNG, having grown up in Port Moresby where, as part of a development project, his father established a printing company.
In her deft execution of the HMHB project, Scoullar benefited from the combined quantum of many decades of experience from the Burnet team.
When I visited with the team in early September, some preliminary results were rolling in from the questionnaires.
They don’t yet shed any new light on the science of stunting. Rather they show, once again, how tortuous is the path from science to successful implementation.
One finding was that birthing centres were not carrying out the recommended practice of swabbing the umbilical cords of newborns with the antiseptic chlorhexidine to protect them from infections. The reason? A lack of supplies and training.
Morgan has also found that in the crucial days straight after childbirth – when 60% of maternal and 50% of newborn deaths occur – only 15 to 20% of mothers are availing themselves of the routine check-up that could treat life-threatening maternal and newborn infections.
Engaging and educating the public does indeed appear to be “harder than rocket science”.
But far from expressing frustration, the researchers appear energised by their findings. In close consultation with the community and the provincial health authority, they are conducting a series of trials to test the best ways to implement chlorhexidine swabbing as well as practical ways to boost check-ups in the first week after birth.
They’ll start with small groups, monitoring as they go and learning from their experience.
To be sure it’s the low hanging fruit, but this careful, stepwise implementation, with community consultation and testing as they go, is the template they will use as the next crop of revelations emerge from the HMHB study.
The team is already discussing what the next step might look like. One proposal, if the data accord with their suspicions, is to test and treat all pregnant women for malaria and other infections in addition to correcting the nutritional deficiencies.
Beeson, for one, is optimistic. While the problem of stunting comes down to a complex interplay of disease, nutrition, constrained resources and community knowledge, he’s confident they will soon see “how the pieces of the puzzle fit together”.
“To me, PNG has such phenomenal potential. We need to find a solution.”
Elizabeth Finkel travelled to Kokopo as guest of the Burnet Institute.
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