ANTANANARIVO, Madagascar -- Miranto is 5 years old. He proudly wears his school uniform, a blue smock, along with Mickey Mouse sneakers and a tilted baseball cap. He's been in school for two years, where he's on track and has made dozens of friends.
Sitraka is a head shorter than Miranto and looks about half his age. He's not wearing any shoes, and his tiny T-shirt reads "Special Baby Boy." He's still learning to speak and has trouble sitting or standing still for any length of time, which means he can't go to school and has trouble making new friends.
Both boys were born in the village of Ambohimidasy Itaosy, about an hour by car outside Madagascar’s capital city of Antananarivo. They were born on the very same day.
But their young lives have diverged already due to a significant difference in the nutrition they received during their first 1,000 days of life, from conception to their second birthday. Whether a child consumes a variety of foods with a diverse range of nutrients can determine much about that child's long-term prospects.
While Miranto's family fed him a variety of high-nutrient foods, Sitraka's family was too poor to do the same. Malnourishment has irreversibly harmed the growth of his body and his brain.
What Sitraka suffers from now is called chronic malnutrition, or "stunting."
Like him, most chronically malnourished children are shorter than their healthier peers. Their immune systems are weaker, leaving them more susceptible to repeated infections. And their brains do not develop fully, leading to lower IQs and a decrease in lifetime productivity.
Stunting is a "life sentence of underachievement and underperformance," said Roger Thurow, author of the book The First 1,000 Days: A Crucial Time for Mothers and Children – And the World and senior fellow for global food and agriculture at the Chicago Council of Global Affairs. What children consume during their first 1,000 days can affect whether "they'll be able to learn in school, their capacity to perform at a job later in life, their earning potential, and then their health throughout life," he said.
It's a global problem, afflicting about 1 in 4 children around the world. When the current generation of stunted children grow up, their reduced potential will cost the global economy at least $125 billion, according to UNICEF. Without investment in proper nutrition, the people of developing countries won't be able to compete in a world market that is "increasingly digitalized and service-oriented," World Bank President Jim Yong Kim stressed in an April speech.
The problem is especially pronounced in Madagascar, where nearly half of children under age 5 are chronically malnourished.
Only four other nations have higher rates of stunting: Papua New Guinea, Eritrea, Burundi and Timor-Leste. But they have smaller populations as well. With its substantially larger population, Madagascar's high rate of stunting translates to an estimated 2 million afflicted children, according to UNICEF.
And while stunting is on the decline globally, the rate in Madagascar has not markedly changed over the last 20 years.
Chronic malnutrition results from a constellation of factors: low incomes, lack of education, insufficient family planning services and poor sanitation. Madagascar struggles with all four.
The country ranks 154th out of 188 countries in the United Nations 2015 Human Development Report. More than 91 percent of its people are living under the international poverty line of $1.90 a day. Only 20 percent have access to safe water, according to the U.S. Agency for International Development, while almost half of the country practices open defecation.
Malnutrition costs Madagascar $740 million per year in lost productivity and health care costs, which is about 7 percent of the country's gross domestic product, according to a study commissioned by UNICEF and the Madagascar government.
Despite the grim statistics, there are solutions. UNICEF estimates that an investment of just $48.4 million per year could substantially reduce malnutrition in Madagascar.
Unfortunately, funding to combat malnutrition in that nation has fallen victim to political unrest and the resulting financial chaos. Madagascar is classified as a developing country and its government has been largely reliant on foreign aid, with some estimates putting it at 70 percent of the budget in 2008. But in 2009, political opposition led by the capital's mayor forced a coup, and donor nations suspended nonhumanitarian aid to the country, stalling economic growth and devastating the national budget. In the absence of foreign aid, social services spending fell dramatically, from 13.4 percent of that budget in 2007 to just 2.9 percent in 2010.
Madagascar's National Program on Community Nutrition, which had been working to educate people in the country's 22 regions about the effects of chronic malnutrition, was paused in 2009 due to the unrest. The program was restarted in 2013 after democratic presidential elections helped restore most foreign aid, but now it covers only the nine neediest regions.
Chronic malnutrition is a top priority for the Madagascar government, said Mamy L. Andriamanarivo, the country's health minister. But a lack of funding limits what they can do.
"We realized when screening that [stunting] is even in the rich regions," said Andriamanarivo. "It's everywhere."
Besides more money, he said, reducing chronic malnutrition will also require educating parents about the need to diversify the foods in their children's diets. Children in Madagascar typically eat staple crops such as rice, which are cheaper and more readily available. Meats, vegetables and other nutrient-rich foods come at a steeper price.
A limited range of foods, along with high rates of parasites, worms and illnesses like frequent diarrhea, creates "the perfect storm" for malnutrition, said Elke Wisch, the head of UNICEF in Madagascar. "These little people basically don't have any chance to fulfill their full potential."
Stunting doesn't usually stop with one generation. Girls who are stunted have their first child on average four years earlier than those who are not, according to a study in the American Journal of Clinical Nutrition. And early child-bearing helps perpetuate the cycle of poverty and malnutrition.
The number of stunted girls giving birth -- some as young as 12 -- factors heavily in Madagascar's high maternal death rate, as their bodies have not developed enough to give birth safely, Andriamanarivo said. Stunted mothers account for up to 20 percent of the country's maternal deaths, according to the Office of Nutrition.
Too little is being done about that in part because a national law dating back to the 1960s stipulates that girls don't reach maturity until 18, according to the health minister. As a result, teenagers don't receive adequate sex education, he said. That contributes to the country's extremely high teen pregnancy rate of 117 births per 1,000 girls aged 15 to 19. (The U.S. rate, by contrast, is 24 births per 1,000 girls aged 15 to 19.)
"Once you're stunted," Wisch said, "you can't fix it."
It's possible that Miranto will go to university some day -- so long as his parents can afford it.
Sitraka’s mother, Mariette, is still desperately trying to teach him how to squat so he can defecate properly. School seems like a distant dream.
Children in Sitraka's situation struggle to get an education, said Virginie Razanatsoa, a nutrition officer for UNICEF who works with Sitraka and Miranto's village. If chronically malnourished kids do go to school, they usually attend for no more than five years, she added. That, of course, lowers their prospects for future employment.
Sitraka has already had surgery for a hernia and recently had blood in his urine. His doctors have recommended that his mother feed him yogurt daily to help supplement his nutrition.
"I'm trying to do my best to give him whatever he wants," Mariette said. But she makes just 1,500 ariary a day -- about $0.47 -- selling food for farmers in the market and doing other odd jobs. That small sum needs to cover expenses for her, Sitraka and his older brother. A single serving of yogurt costs about one-fifth of the family's daily income.
While the United Nations has made it a priority to end child malnutrition by 2030, this year's Global Nutrition Report stated that greater investment and committed action are needed to get anywhere close to that goal. In Madagascar, another coup -- political observers say that's certainly possible -- could lead to another mass withdrawal of international aid dollars, devastating any progress that's been made.
Meanwhile, the stunting cycle continues, leaving another generation behind.
"Equal opportunity for all is an empty slogan if we don’t address this issue," the World Bank's Kim said in April.
Making sure that children in developing countries get proper nutrition is a moral and economic imperative, said Thurow, the global malnutrition expert.
"If you ask why some countries remain poor or why development aid isn't as effective as possible and doesn't have the impact we think it should, it's because so many kids are getting off to a horrible start in life," he said.
"What might a stunted child have accomplished and contributed to all of us in the world had they not been stunted? The lost chance of greatness for one becomes a lost chance of greatness for all of us."
Graphics by Alissa Scheller.
RESULTS, a nonprofit anti-poverty advocacy group, funded this reporting trip to Madagascar to highlight the country's health challenges. It had no role in the writing or editing of this article.