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Trees of Hope: The potential of Moringa oleifera to nourish Haiti

[Background document]

Vanessa Pike (Young), RD, MPH(c)

Master of Public Health – Community Nutrition Summer Research Practicum

University of Toronto

May 22, 2015

“No other plant…appears able to match [the moringa’s] combination of overall utility, micro- and macronutrient composition, rapid growth habit, high yield leaf

production, and survival in harsh climates.” ~ Thurber and Fahey, 2009

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Table of Contents Introduction .......................................................................................................................... 3

Malnutrition .......................................................................................................................... 3

The Haitian Context ............................................................................................................... 3

Introducing Moringa .............................................................................................................. 7

Moringa Nutrition ................................................................................................................. 8

Moringa as Food .................................................................................................................... 9

Moringa Interventions in Other Countries ............................................................................ 11

The First 1000 Days.............................................................................................................. 13

Moringa in Haiti .................................................................................................................. 14

Food-based Approaches to Addressing Malnutrition ............................................................ 16

The Value Home Gardens .................................................................................................... 17

Multisectoral Approach ....................................................................................................... 18

Social Marketing of Moringa ................................................................................................ 18

Conclusion ........................................................................................................................... 19

References .......................................................................................................................... 20

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Introduction Hunger and micronutrient deficiencies are crippling problems in Haiti, a fragile country facing mammoth challenges to development. There is a local resource, however, in the form of a humble tree that can be taken advantage of for boosting food security, health, and economic development. This paper will first outline the effects of malnutrition, then Haiti’s historical, political, geographical, and development context. Next, the moringa tree and its benefits will be introduced, and interventions involving its use will be highlighted. Then, an overview of what has been done in Haiti so far with moringa will be given, and the merits of food-based and home garden approaches to reducing malnutrition will be discussed. Finally, the potential of social marketing in moringa promotion will be outlined.

Malnutrition Malnutrition contributes to one third of all child deaths globally, and lack of access to nutritious food is often the cause (WHO, 2015b). Haiti, a country of about 10.3 million (WHO, 2015a) sharing the island of Hispaniola with the Dominican Republic, is all too acquainted with hunger as about one third of its population is food insecure (WFP, 2015b). The 2013 Global Hunger Index (GHI), a tool by the International Food Policy Research Institute (IFPRI) to track and compare hunger by region and country, indicates that Haiti’s score of 23.3 is at the level of “alarming” (IFPRI, Concern Worldwide, and Welthungerhilfe, 2013). As is so often the case, the burden of malnutrition lands heaviest upon women and young children, leaving them undernourished and deficient in key vitamins and minerals (Government of the Republic of Haiti, 2010; USAID, 2014) and thereby hinders both the development of human potential as well as national economic development (Zongo, Zoungrana, Savadogo, and Traoré, 2013). Chronic malnutrition affects one in every five children in Haiti, and 6.5% suffer from acute malnutrition. These rates vary geographically with rural being most affected. For children under 5 years of age, the prevalence of stunting is 22%, and the prevalence of underweight is 11% (USAID, 2015). Micronutrient deficiencies are also widespread; more than half of Haiti’s women and children suffer from anemia (WFP, 2015b), 32% of preschool children are deficient in vitamin A, and almost 60% of school-aged children are iodine deficient. Zinc intakes are also inadequate for a large portion of the population (Micronutrient Initiative, n.d.). These nutrition outcomes are influenced by constraints in the health care system (USAID, 2014), but have much deeper root causes.

The Haitian Context As accurately explained by Kimura (2013), hunger and malnutrition are complex issues rooted in history, influenced both global and local natural, political, and economic factors. Haiti has struggled for decades with high levels of poverty and food insecurity, along with recurrent

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natural disasters, political instability, and high population growth (USAID, 2015). In 2014, Haiti ranked 168 out of 187 countries on the Human Development Index – a composite index measuring health, lifespan, knowledge, and standard of living (UNDP, 2014). As one of the poorest countries in the world, more than half of the Haitian population lives on less than $1 US per day (CHAI, 2013) and over 80% live on less than $2 per day (USAID, 2014). This affects not only individuals, but also communities, the operation of administration, and therefore the entire country. Unemployment rates are at 50% in the nation’s capital, and illiteracy rates are about the same (USAID, 2014; WHO, 2015b). Although Haiti has made some progress towards education, access remains low and the average citizen receives a mere 4.9 years of schooling (CHAI, 2013) – a particularly relevant statistic since it is known that maternal education is inversely related to stunting (USAID, 2014), and education is a strong predictor of food security (Canadian Feed the Children, 2015). The mountainous geography coupled with the tropical weather of Haiti also leaves the country prone to natural disaster (CHAI, 2013). Frequent tropical storms and hurricanes batter the landscape – so much so that it has been said that “every summer, Haitians fear nature’s wrath” (IFPRI, Concern Worldwide, and Welthungerhilfe, 2013). Localized droughts and floods also occur and lead to massive erosion and disrupted ecosystems, exacerbated by the limited capacity of authorities to respond to crises (IFPRI, Concern Worldwide, and Welthungerhilfe, 2013; WFP, 2015b). Perhaps the most memorable recent natural disaster occurred on January 12, 2010, when a massive earthquake struck Haiti, resulting in the death of over 200 000 people and the displacement of over 1.5 million. Much of the country’s vital infrastructure was destroyed and 40 million m3 of debris was created (Feldmann, 2013; Government of the Republic of Haiti, 2010; Vertefeuille, Dowell, Domercant, and Tappero, 2013). Just 10 months later, Haiti experienced its first (and most severe) cholera outbreak in a century, affecting 470 000 people (CDC, 2011). Two short years later in 2012, Tropical Storm Isaac and Hurricane Sandy assaulted Haiti causing major flooding and crop damage, as well as blocking access to some communities altogether. While not a new phenomenon, the frequency of weather shocks are increasing, and in 2012 Haiti was ranked as the country at the most extreme risk worldwide in vulnerability to climate change (Maplecroft Global Risk Analytics, 2012). These natural disasters frequently destroy many of the crops used for subsistence farming (World Bank, 2013) driving up food prices and worsening the devastation (IFPRI, Concern Worldwide, and Welthungerhilfe, 2013). According to USAID (2014), the average number of meals per person per day decreased from 2.48 to 1.58 after the earthquake, and the percentage of food insecure households rose from 40% to 52% (Government of the Republic of Haiti, 2010). Of the households affected by the 2010 earthquake, over half were already in debt – a debt almost wholly related to food purchases (Government of the Republic of Haiti, 2010). The fact that the majority (63%) of Haiti’s land mass is considered too steep for crop or livestock production (Columbia University Earth Institute, 2012) also cuts into agro-economic opportunities.

Electricity is scarce in Haiti, with only about a quarter of the population having access, many for only several hours a day (USAID, 2015). As a result, charcoal (made from wood) is relied upon as

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a main energy source for cooking. Because selling it is the only option for income for many Haitians, 30 million trees are being cut down each year – one of the highest rates of deforestation in the world – and Haiti now has only 2% of its original tree cover remaining (Smallholder Farmers Alliance, 2013 and 2015). This extreme deforestation has eroded the landscape to produce treeless mountains and soil erosion which facilitates flooding and landslides (especially during hurricane season) – further degrading the land and reducing agricultural potential. Drinking water is also polluted and fish stocks are damaged with sediment deposition, propelling the vicious cycle (Interlandi, 2010; USAID, 2015).

The stress on Haiti is not solely due to the environment, however. In addition to natural forces, the agriculture sector is hindered by a history of underinvestment in infrastructure and poor resource management (USAID, 2014). As only 10% of crops are irrigated, the vast majority of farms rely on rainwater (WFP, 2015a), and fertilisers are used on only 5% of farms (Government of the Republic of Haiti, 2010). Although agriculture accounts for up to 40% of the country’s GDP and 60% of its population make their livelihoods through agriculture (Smallholder Farmers Alliance, 2015; USAID, 2014), still about half of Haiti’s food is imported, including 80% of its staple, rice (USAID, 2015a). Nonetheless, efforts are in place to reform the agri-food system. For example, in 2012, shortly after Hurricane Sandy, the Haitian government announced plans to increase production capacity with a goal of meeting 60-70% of the country’s food needs by 2017 (IFPRI, Concern Worldwide, and Welthungerhilfe, 2013). Large agribusinesses continue to dominate, however, and there has been little investment into the revitalization of Haiti’s agriculture system through small farmers (IFPRI, Concern Worldwide, and Welthungerhilfe, 2013). This history of weak governance leads Haiti to be classified as a fragile state due to serious gaps in security, constitutional laws, and economic development (IFPRI, Concern Worldwide, and Welthungerhilfe, 2013), and also leaves Haiti relying heavily on foreign aid and the work of NGO’s. For example, in the 29 months after the earthquake in 2010, roughly $9 billion of aid from foreign governments and private donations came into Haiti (Locke, 2012). The return on investment, however, has been hindered by a disorganized channelling of resources and layers of procedures among the receiving bodies – the vast majority of whom are NGO’s. According to the United Nations, only 1% of post-earthquake relief and 12% of recovery aid was channeled through the government (Office of the Secretary General’s Special Adviser, 2013). Haiti has become infamously known as a “republic of NGO’s” due to the thousands of international entities that work within its borders (Feldmann, 2013). This has become even more pronounced since the earthquake – despite resolutions to allow Haitian government to take the lead – when estimates of the number of NGO’s in Haiti ballooned to 10 000 (USIP, 2010). Coordination of the activities of these organizations amongst a backdrop of political instability and weak infrastructure has been poor. Although NGO’s are largely responsible for the rebuilding of Haiti, they generally lack the expertise to work according to a long-term plan with a comprehensive understanding of the country’s needs (Feldmann, 2013). Many NGO’s also attract well-trained locals to work for them instead of equivalent positions within government by offering much better compensation and benefits (Garrett, 2007). This has led to

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an essential take-over of NGO’s providing public services and a perpetuation of the cycle of low capacity and accountability in Haitian leadership (Garrett, 2007). It could be argued that the good intentions of donor countries actually do Haiti a misdeed, locking the country into a dependency on aid as opposed to contributing to a more capable public sector (IFPRI, Concern Worldwide, and Welthungerhilfe, 2013). But this phenomenon of dependency is not new. The structural adjustment programs in the 80’s have been criticized for fostering a dependence on imports as opposed to encouraging local production solutions from the Haitian people (IFPRI, Concern Worldwide, and Welthungerhilfe, 2013). Food distribution programs, for example, made it difficult for local farmers to compete with low imported food prices. This heritage of import reliance has left its mark on the Haitian food system, making Haitian consumers sensitive to fluctuations in the world market (IFPRI, Concern Worldwide, and Welthungerhilfe, 2013). According to Labonte and Torgerson (2005), “public policies determine the ultimate allocation of opportunities and resources” in a country, and Haiti is no exception. Haiti’s lack of land ownership rights has long been a long-standing issue, influenced by the country’s colonial predecessors and post-colonial policies discouraging rural tenure (Columbia University Earth Institute, 2012). This legacy was especially damaging after the 2010 earthquake as it impeded reconstruction and kept people living in temporary shelters. Urban sprawl and uncoordinated regional planning led to unauthorized construction on agricultural land and crops being grown on unsuitable land (Feldmann, 2013; World Bank, 2010). For example, small scale farmers are increasingly using steeply sloped land which contains fragile soil, unfortunately contributing to erosion in the process. As a result, most farmers in Haiti use several dispersed plots of land, while large-scale farmers and industrial companies have easily acquired fertile land (IFPRI, Concern Worldwide, and Welthungerhilfe, 2013). Rapid urbanization combined with a lack of public services greatly diminishes community capacity (Labonte and Torgerson, 2005). Adding to the equation brain drain from government jobs along with longstanding political instability, little policy capacity remains for developing and maintaining the public sector. As alluded to above, even some of the most fundamental government services such as security, sanitation, education, energy, and taxation are lacking in Haiti (Feldmann, 2013). Consequently, most of Haiti’s reserves of more hidden natural resources such as gold, copper, and silver have not yet been explored (Oxfam America, 2012). Evidently there is a pressing need for global governance and tighter regulation of NGO’s in Haiti to empower local leadership. It is only through strategic management of Haiti by Haitian people that the collective population’s long-term best interests can be attended to; a country cannot be effectively led by forces beyond its own borders.

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Introducing Moringa

One of the most promising ways for increasing food and nutrition security in Haiti – and potentially increasing economic opportunity as well – involves the unique Moringa oleifera (moringa) tree, (known as the ‘benzoliv tree’ in Haiti (ECHO, 2007)). It would be difficult to overstate the potential of this nutritious, easily-cultivated, multi-purpose tree. Belonging to the Moringaceae family which is in the Brassicales order (including cabbage, radish, and capers) (Olson and Fahey, 2011), the moringa tree produces nutritious leaves, flowers, bean pods, and oil (Martín et al., 2013). Native to northern Pakistan and India, the moringa tree has been introduced (and has flourished) all over Asia, Africa, South America, southern Florida, and the Caribbean, and is available in almost every part of the world still affected by malnutrition (Mahmood, Mugal, and Haq, 2010; Martín et al., 2013, Smallholder Farmers Alliance, 2015); there are records of indigenous knowledge and use of moringa across 80 countries in over 200 languages for thousands of years (Mahmood, Mugal, and Haq, 2010). The moringa is such a versatile plant that many refer to it as a “miracle tree” or “tree of life” (Smallholder Farmers Alliance, 2015). Examination of the tree’s many applications and benefits makes it clear why.

Almost every part of the moringa tree can be useful, making it a potential income source both directly and indirectly. Beyond cultivating moringa for food, its benefits extend into other areas of agriculture. Farmers use the seeds and shoots as a fertilizer to enrich the quality of the soil, thereby increasing plant growth (ECHO, 2007). Moringa’s leaves and seeds are also useful as nutritious fodder for fish and poultry (Smallholder Farmers Alliance, 2015; Thurber and Fahie, 2009; Yisehak, 2011); allowing them to grow more robust and benefit the farmers through overall increased yield. The trees themselves are often used as living fences to protect against animals and wind, or to prevent erosion of other crops (ECHO, 2015; Yisehak, 2011). The wood is quite soft and lends itself well to paper- and rope-making, and can also be used to create a blue dye (ECHO, 2007; Yisehak, 2011). Furthermore, its flowers are a good year-round source of nectar for honey bees (Republic of Haiti, 2013; Smallholder Farmers Alliance, 2015; Yisehak, 2011). Moringa seeds are a wonder in and of themselves. Not only are they rich in oil for biofuel, cooking, and for use as lubricant (ECHO, 2015; Yisehak, 2011), but an impressive quality, once crushed, is their ability to clarify and purify turbid water with its flocculating and anti-microbial properties (ECHO, 2015; Martín et al., 2013; Smallholder Farmers Alliance, 2015; Yisehak, 2011). Moringa flowers and oil are also gaining ground as a new trend in the cosmetics industry in fragrance and skin care products (The Body Shop International, 2015; Smallholder Farmers Alliance, 2015), and the antioxidants in moringa have led to exploration of the use of moringa as a natural alternative to food preservatives (Olson and Fahey, 2011). Having impressive claims of medicinal applications, moringa leaves, bark, roots, and seeds have been used by traditional healers for hundreds of years for the treatment conditions such as skin diseases, joint pain, infections, headaches, diarrhea, and even chronic diseases such as hypertension, diabetes, anxiety, cancer treatment (Mahmood, Mugal, and Haq, 2010; Thurber and Fahie, 2009; Trees for Life International, 2011). Although not common in Western medicine, doctors in some countries also use moringa in disease prevention due to its anti-

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inflammatory, antimicrobial, antioxidant, anti-tumor, hypoglycemic, and anti-hypertensive properties (Martín et al., 2013; Olson and Fahey, 2011; Trees for Life International, 2011). The seed pods are also an important source of fibre (Yisehak, 2011). These properties of Moringa can have the added benefit of helping to protect against chronic disease increasing among low-income countries, thereby helping to reduce the double burden of disease. This giving plant is also an agricultural wonder. With its natural pest resistance and ability to thrive in hot, dry climates, (Yisehak, 2011) it is available even with many other crops are not. It costs little to plant and can be grown from either seedlings or cuttings (Thurber and Fahey, 2009), and older flowering branches can be pruned to continuously produce new leafy shoots for food (Yisehak, 2011). The moringa tree is a source of food year-round as the leaves can be eaten fresh during growing season and dried for use during other parts of the year (Yousefian, 2012). Due to the ease and speed with which it is cultivated, it can be used on a large scale – up to 15 feet from a seed in one year – and can grow interspersed with other crops (Smallholder Farmers Alliance, 2015). Overall, moringa trees have low nutrient and water requirements and is able to grow in very dry, sandy soil (Smallholder Farmers Alliance, 2015). The moringa tree can produce quite a generous yield when properly planted and fertilized. Ideal seed spacing for leaf production is 30 inches within rows and 1 meter between rows, although beds with 4 x 4 inch spacing might be the most feasible for the home gardener (Radovich, 2009). Seeds should be planted about 2 centimeters deep in soil kept moist (ECHO, 2007), and seedlings pruned at 1 meter tall to encourage more branches to grow from the sides (Radovich, 2009); regular pruning produces maximal output – up to nine harvests per year from the same plants (Thurber and Fahey, 2009; Trees for Life USA, 2010). It has been estimated that 10kg of seed produces 1.3 litres of oil (Radovich, 2009), and that each tree can produce 1-5kg of fresh leaves per year, but ultimately yields vary widely with cultivation techniques (Radovich, 2009; Smallholder Farmers Alliance, 2015). Leaves can be harvested in as little as four months after planting, and most produce bean pods within a year (Smallholder Farmers Alliance, 2015).

Moringa Nutrition The nutritional properties of moringa are perhaps the most astounding. The leaves of the moringa tree are a nutritional goldmine, providing protein, calcium, iron, vitamin A, Vitamin C, and B vitamins in amounts rarely seen in one single food. Although reports of nutrient content vary by source (and are also influenced by harvest season and geographical region), generally 100g of fresh leaves contains more calcium than milk, more iron than beef, soybeans, or enriched grains, about double the protein of quinoa or half the protein in eggs, as much vitamin A as carrots, more than three times as much vitamin C than oranges, almost as much potassium as bananas (Yisehak, 2011 compared with Canadian Nutrient File, 2010). Assessed in another way, per 100 g of fresh weight, Radovich (2009) reports that moringa leaves contain over 7500 IU of vitamin A, 51.7mg of vitamin C, 185mg calcium, and 337mg potassium (although caution should be used when interpreting these amounts since quantities

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vary by source). For a young child, even a relatively small amount of powder or fresh leaves would provide a large amount of his daily nutrient needs, including these along with B vitamins and essential amino acids (Smallholder Farmers Alliance, 2015). Moringa oil, as well, added to the diets of young children has proven beneficial as a concentrated source of energy and vitamins (Smallholder Farmers Alliance, 2015). Importantly, anti-nutritional factors such as tannins, protease inhibitors, and lectins are also low (Olson and Fahey, 2011). One of the most nutritionally-relevant features of moringa leaves in settings of malnutrition are their high protein content – up to 30% of its weight (Olson and Fahey, 2011). Moringa leaves contain all the essential amino acids in a well-balanced profile (Martín et al., 2013; Olson and Fahey, 2011; Trees for Life USA, 2010), including significant amounts of sulfur-containing methionine and cysteine which are usually present in very small amounts in plant sources (ECHO, 2007). Moringa therefore holds significant potential in the diets of those who do not have access to much meat. In powdered form, the leaves contain more concentrated amounts of nutrients, comparable with powdered milk for its calcium and protein content and additionally has vitamin A (Olson and Fahey, 2011). With these amounts of macro- and micronutrients, it is not difficult to see how consuming moringa regularly could completely revolutionize the health of a malnourished individual. Furthermore, if these nutritional benefits were understood by populations, there would be a far greater demand for it as a commodity, and the population health benefits could be considerable. Not surprisingly, many organizations (including the FAO) have noticed the potential of moringa and have incorporated it into their strategies and programs to combat malnutrition and food insecurity, particularly among children and pregnant and lactating mothers (Martín et al., 2013; Smallholder Farmers Alliance, 2015). Moringa powder is commonly used as a nutrition supplement in Africa and other parts of the world where 1-2 teaspoons are added to cooked food daily to enhance its nourishing ability (Radovich, 2009). Indeed, addition of moringa to diets of extremely malnourished people in West Africa has been documented as “saving their lives” (Olson and Fahey, 2011).

Moringa as Food

Of course a food must be palatable if it is to be regularly eaten. In this case, the moringa tree scores moderately well. From a culinary perspective, all parts of the tree are edible except the wood, and taste perceptions range from “tasteless” to “slightly bitter,” depending on the geographic origin of the leaves (Thurber and Fahey, 2009). Acceptability has been demonstrated even among children (Thurber and Fahey, 2009). The variety of ways in which this valuable “miracle tree” can be consume make it a versatile ingredient. There are numerous sources of moringa recipes online which incorporate moringa leaves, flowers, and bean pods into sauces, stews, smoothies, stir-fries, traditional food, teas, and even treats like chocolate truffles.

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The leaves of the moringa tree are the most extensively used of all parts of the tree (ECHO, 1996). Essentially a substitute for spinach or any other leafy green, moringa leaves even more nutritious (ECHO, 2007). Both young and old leaves are eaten, but older ones are preferred due to having a milder taste. Tea is sometimes made from dried leaves, and fresh leaves can be added to sauces and stews (Yisehak, 2011), soups, or even consumed raw in salads (Martín et al., 2013). The taste of fresh leaves varies from “radishy” and hot to quite mild (Doerr et al., 2009). Boiling the leaves has been shown to enhance their antioxidant activity (ECHO, 2007). Young and old leaves alike can be harvested for drying, and should be processed the same day by washing, draining, then drying the leaves in the shade (as direct sunlight can destroy some of the vitamin A) or dehydrated in a dehydrator. The dried leaves are then pulverized using a mortar and pestle (or by machine) and sifted to produce a fine powder, sometimes called moringa flour. The powder should be stored away from heat, light, and humidity in order to preserve nutrients; it lasts up to 6 months in air-tight containers (Mishra, Singh, and Singh, 2012; Radovich, 2009). A big advantage of drying and powdering moringa leaves is that it makes this nutritious food available throughout each season, even during drought (Yisehak, 2011). Moringa powder can be used in place of fresh leaves in cooking (Yisehak, 2011), or combined with locally-available and commonly-consumed foods such as peanut butter (Simms, 2010). Moringa powder is mixed with porridge and other semi-liquid food and used in complementary feeding in many areas, accepted in appearance and taste despite the green color imparted onto the food (Zongo, Zoungrana, Savadogo, and Traoré, 2013). In the Philippines, moringa powder is mixed with flour and used in bread making (in particular, “nutri-buns” for use in school feeding programs) (The World Vegetable Centre, n.d.). Most commonly, though, moringa powder is sprinkled on food just before eating in order to maximally preserve nutrients (Radovich, 2009). Moringa oil (better known as `ben oil`) has been shown to be a better oil for deep frying than canola and soybean and palm oils due to its stability at high heat, as well as having high monounsaturated fat content (Abdulkarim et al., 2007). Ben oil is also rich in tocopherols and similar to olive oil chemically and physically. In Haiti, ben oil is used in salad dressings, for stir-frying, and in marinades, having a slightly nutty flavor (Martin et al., 2013; Smallholder Farmers Alliance, 2015). It can also be used to stabilize other oils by helping reduce oxidation, improving their culinary use (Martin et al., 2013). Moringa flowers are used both for nutritional and medicinal benefits. Considered a delicacy in some countries, flowers which reportedly taste like mushrooms are often mixed into other dishes or fried and eaten as a snack (Martín et al., 2013; Smallholder Farmers Alliance, 2015) They are also steeped in water to make a tea used as a cold remedy (ECHO, 1996; Smallholder Farmers Alliance, 2015).

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The seed pods of moringa begin as small tender green pods which taste like asparagus and are often eaten like green beans (Martín et al., 2013; Yisehak, 2011) or as a substitute for okra (ECHO, 1996). As pods mature, they elongate to about 15 inches and become more fibrous and can be boiled and seasoned as any bean, but are more often cracked open for extraction of the green seeds which are cooked like green peas, or the more mature seeds which can be fried, roasted like peanuts, used in sauces and stews, or ground into a powder and used as a spice (ECHO, 1996; ECHO, 2015; Martín et al., 2013; Smallholder Farmers Alliance, 2015).

The roots of moringa trees are less commonly used for culinary purposes, but are known to taste like horseradish (hence another name for moringa is `horseradish tree`). Roots can be used to create sauces or as a spice, and also serves medicinal purposes (ECHO, 2015; Martín et al., 2013; Smallholder Farmers Alliance, 2015), however some warn of toxic effects when roots are consumed in large quantities due to the presence of a nerve-paralyzing agent spirachin (ECHO, 1996; ECHO, 2015).

Moringa Interventions in Other Countries* *not an exhaustive review

The moringa tree has unfortunately been “one of the most underutilized tropical crops” (Oduro, Ellis, and Ousu, 2008). According to a list of global food commodities in 2013 by the Food and Agricultural Organization’s Statistics Division, moringa was not even one of the top 50. This is a disproportionate amount of production compared with the need for nourishment around the world. Its benefits are being tapped into in some countries (particularly in Sub-Saharan Africa), however, and the results are encouraging. Success has been seen in using moringa as a tool for building sustainable communities in the tropics (Olson and Fahey, 2011), addressing malnutrition, and of improving livelihoods. A longitudinal study in Burkina Faso documented the ability of moringa in the diets of severely malnourished children. Results showed that compared to those who received standard care, children receiving moringa powder as an additional supplement experienced more weight gain, quicker recovery, and dramatically lower rates of diarrhea (Zongo, Zoungrana, Savadogo, and Traoré, 2013). Although there were no differences in hemoglobin status between the two groups, it was suggested that analysis of another related parameter such as serum ferritin could have been more telling (or, that it could have been due to the low bioavailability of iron in Moringa leaf powder) (Zongo, Zoungrana, Savadogo, and Traoré, 2013). Local health workers in Senegal are now using moringa for malnutrition instead of imported goods because “it’s accessible and indigenous” (Trees for Life USA, 2010). One Senegalese woman, a supervisor of a primary health unit, said “We have always had problems with the classical approach to treating malnourished children…based on industrial products: whole milk powder, vegetable oil and sugar. All these things are expensive. When you tell a parent to go out and buy them—this can be truly costly for them” (ECHO, 2007). One of the main advantages of the moringa tree as a partial solution to food security is the fact that it is a local

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resource. It would not be viewed as a ‘Western’ solution, but a part of the land to which the people belong and a solution in which they can take pride. In Nigeria, the Faculty of Agriculture and Forestry at the University of Ibadan, in cooperation with the Community Integrated Rural Development Project (CIRDP), with a grant through the MacArtuhur Foundation, implemented a moringa training program for rural women. The result has been community members developing processing and marketing skills as moringa is grown and sold, generating income and community well-being. The women and community members have also been reporting health improvements from regularly consuming moringa (DRUSSA, 2013). The initial crop of moringa trees was planted to be ready for harvest once the women finished their training, but since then, women have added to the moringa plantation and report making additional income (DRUSSA, 2013). This is intervention is sustainable as the women were not only educated, but empowered with the tools they needed to start off, and linked with a market for uptake of their product, while simultaneously providing them a way to make a living. While not involving moringa specifically, a study by Farber et al. (2002) has important parallels which are relevant to this discussion. Yellow and dark green leafy vegetables grown in home gardens were promoted in order to increase the serum retinol concentrations of children of low-income households in rural South Africa. Over 125 home gardens were established (about one third of households), and at the end of the 20-month intervention involving educational components, significant increases were seen in consumption of these vegetables, serum retinol concentrations of children, along with maternal knowledge of vitamin A. Intake of other essential micronutrients were significantly increased in the intervention group compared to the controls as well. The authors point out that linking this type of intervention with both nutrition education and primary health care activities (in this case, growth monitoring) are key to success, particularly among rural populations not having direct access to health facilities and commercially-available fortified food (Farber et al., 2002). Home gardening integrated with multisectoral community programming (encompassing health care, agriculture, nutrition, and education) was perhaps a ‘perfect storm’ in this case. And finally, the Mukono District in central Uganda was the site of a recent nutrition education intervention promoting moringa at the household level. Women were educated about nutrition, the benefits of moringa, and how to incorporate it into their family cooking through commonly consumed foods. After four weeks, improvements were noted in knowledge, attitudes, and utilisation of moringa (Mukama, 2014). Also, several Grand Challenges Canada grants are currently exploring the use of moringa to combat nutrient deficiency in various countries (Grand Challenges Canada, n.d.). While perhaps not directly applicable to or replicable in Haiti, parallels can be drawn and the lessons learned from such examples can provide valuable insight and principles for developing moringa programs in Haiti.

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The First 1000 Days

An emphasis on the critical first 1000 days of a child’s life as key for targeting nutrition has been promoted by the WHO, UNICEF, World Food Program, and other funding agencies worldwide (www.thousanddays.org). There are important applications of moringa’s use for this time period. Moringa is widely promoted and used as a supplement for both nursing mothers and weaning infants (Doerr et al., 2009; ECHO, 2007; The Hunger Project, 2013; Radovich, 2009). For a pregnant or breastfeeding woman, one small portion of fresh leaves or powder could provide her with a large proportion of her daily calcium needs, and significant amounts of iron, protein, and B vitamins, which could help reduce infant mortality and morbidity. These nutrients in moringa crucial for healthy pregnancy have been measured. According to biochemical analysis conducted in Fiji, 100 grams of fresh moringa leaves contain approximately 86 µg of folic acid (Devi, Arcot, Sotheeswaran, and Ali, 2008), or about 20% of daily requirements for pregnant women according to the WHO’s recommendation of 400 µg per day (WHO, 2012). The same amount of moringa leaves contains 5-8 mg of iron, and moringa powder contains an even more concentrated amount of 18-28 mg in 100g (Smallholder Farmers Alliance, 2015). Measured against the WHO’s recommendation of 30-60mg of elemental iron per day for pregnant women (WHO, 2012), moringa can provide significant proportions of the daily iron requirements. As only 30% of Haitian women meet the recommended daily intake for iron (contributing to anemia and consequential complications for both mother and baby (USAID, 2014)), moringa could truly be transformative in this area. However, it should be taken into consideration that some have recorded a low bioavailability of iron in moringa leaf powder (Zongo, Zoungrana, Savadogo, and Traoré, 2013), and nutrient composition of moringa varies by source. Moringa can also help with breastfeeding and weaning. In a review of six randomized control trials, Raguindin, Dans, and King (2014) show that eating moringa significantly increases serum prolactin levels, thereby increasing breast milk production, with no accompanying adverse events. Overall there was a significant increase in the weight of infants – a 12% difference after four weeks compared with controls. Perhaps this is how the moringa came to be called “mother’s best friend” (ECHO, 2007)! Similarly, moringa has beneficial applications in complementary feeding once children begin weaning. Complementary foods used in developing countries are often of low nutritive value (usually cereal-based) with low protein levels and poor protein quality (Shiriki, Igyor, and Gernah, 2015). Fortification of these foods with moringa powder, however, can dramatically improve their nutrient profile with very little increase in cost. In a trial of complementary food formulations, maize, soybean, and peanut blends fortified with 10% moringa flour gave the best performance compared with those with less or no moringa (Shiriki, Igyor, and Gernah, 2015). These results are significant because children who are better nourished as infants grow up with fewer physical and developmental impairments. The cycle of poverty could be could be dealt a severe blow if a generation of children grew up with optimal nutrition.

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Moringa in Haiti The average Haitian diet is based largely on starch stables (rice, corn, wheat, millet) and vegetable oil along with beans, yams, fruit, and smaller amounts of chicken, pork, goat, seafood (Food in Every Country, n.d.; World Food Program, 2015c). Considering the rates of food insecurity as outlined above and this typical diet low in vegetables, the addition of moringa could be quite beneficial. Actually Haitians are already familiar with eating local leafy greens (E. Boldon, personal communication, May 13, 2015), so it may not be difficult to encourage the incorporation of moringa. As Haiti’s climate is favorable for its growth and it already thrives naturally across most of the country, moringa is already used by farmers as natural fencing and animal fodder, and its medicinal properties have made it a trusted folk remedy (Smallholder Farmers Alliance, 2015). The government of Haiti has nutrition as a priority. A national strategic framework to eradicate hunger and malnutrition by 2025 and a national-level Commission for the Fight Against Hunger and Malnutrition (COLFAM) provides direction to government ministries and NGOs (USAID, 2014). In 2012, Haiti joined the international Scaling Up Nutrition (SUN) movement which unites stakeholders in multisectoral collaboration for nutrition improvement (USAID, 2012), and also developed a national Nutrition Strategic Plan for 2013-2018 which adopts a community-based, collaborative, holistic approach to preventing malnutrition (Republic of Haiti, 2013). A working group of Haiti’s Ministry of Public Health and Population (MSPP) recently published a concept document (2013) for the adoption and large-scale production of moringa as a strategy to combat malnutrition, which stems from Haiti’s National Strategic Plan for Nutrition. According to the report, a “moringa program” could make a difference on nutritional, environmental, and economic axes (Republic of Haiti, 2013). Some particularly relevant priorities set by the government in these documents include the nutrition and health of vulnerable groups (pregnant and breastfeeding women and children under 5) (Republic of Haiti, 2013). There is also a written aim to promote the use of local nutritious agricultural products (especially fruits and vegetables), and promoting dietary diversification (Republic of Haiti, 2013).

Haiti also has a specific plan for continuing recovery and redevelopment from the earthquake and beyond. About 2 months after the earthquake in 2010, the Haitian government along with support from several international organizations conducted a detailed post-disaster needs assessment which outlines the losses and damages across sectors and proposes major areas for action in the short, medium, and long-term for rebuilding a new Haiti. Some of the goals under the nutrition and food security section are quite congruent with the production of moringa, including putting in place a system of “multi-skilled agents” at the community level for malnutrition prevention. Support is called for the more than 1 million small scale farmers in order to ensure a regular food supply for rural populations. Another goal is to increase the number of food products offered in the country (through improving input and marketing), as well as creating rural jobs (Government of the Republic of Haiti, 2010). Moringa could be key in carrying out these plans.

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Also under the MSPP action plan, schools will grow moringa and incorporate its leaves or powders in school lunches at least once per week. Teachers would be trained to show their students how to grow moringa, and students could in turn bring this knowledge to their parents, with the ultimate goal of every family having a tree from which they gather leaves for home meal preparation (MSPP, 2013). To get the process started, a large-scale moringa promotion day was held in June of 2013 involving over 500 schools which brought together the Ministries of Education, Agriculture, Natural Resources, Rural Development, and Public Health to popularize moringa among students (Le Nouvelliste, 2014). Around the same time the Haitian Moringa Network (or “Rezo Moringa-Benzoliv Ayiti”) was formed. A public-private platform for moringa stakeholders, the network is composed of community, NGO, and government representatives who share information and promote the production and consumption of moringa in Haiti (Holla, 2014; Smallholder Farmers Alliance, 2015). Promotion through these venues has gone beyond encouraging consumption and also involved highlighting moringa’s usefulness as animal and fish fodder, for water filtration, and in beauty products (Smallholder Farmers Alliance, 2015). Overall, the MSPP has a goal of planting more than 10 000 hectares of moringa by the year 2018 (MSPP, 2013). Besides the nutritional elements of the MSPP plan, two other areas of potential were highlighted. An environmental benefit of large-scale moringa production would be a counteracting of deforestation and the stabilization of soil through its ability to grow on slopes and difficult terrain due to its root structure which helps absorb water and hold soil in place (Interlandi, 2010; MSPP, 2013). Also, an economic benefit would follow from using moringa to feed livestock (lessening the need to import expensive animal feed) and using moringa oil (reducing dependence on imported edible oils) (MSPP, 2013). The rapidly-expanding international market for moringa also presents great potential, since it is becoming viewed as a new “superfood.” Local demand in Haiti is small but growing, particularly among NGOs using it as a tool to help fight malnutrition (Doerr et al., 2009; Smallholder Farmers Alliance, 2015). Prices for moringa powder vary greatly, from $14 - 36 USD per pound; other products such as moringa peanut butter, oil, and capsules are also being marketed. Some moringa is sold locally (mostly in the capital Port-au-Prince). While the majority of these initiatives are informal operations, there is a rising interest in growing more moringa for commercial enterprise (Smallholder Farmers Alliance, 2015). Moringa trees are inexpensive to obtain in Haiti (about $0.25 each), and even if seeds cannot be funded, moringa can be propagated through direct seeding or cuttings (Holla, 2014). It is also simple to process, without requiring expensive equipment. However there remain several barriers to its use. Irrigation systems may be needed for large-scale production in some areas (Smallholder Farmers Alliance, 2015) (although home gardens and smallholder farms would not). Also, the MSPP describes a “distrust reflex” among rural populations for new crops since they have often been offered agricultural products to cultivate for which there was no stable commercial market (2013). And although up to 70% of Haitians know about the existence of moringa, it is severely undervalued (MSPP, 2013) and much work remains to be done in its promotion. As tradition plays a role in the adoption of foods, there is a possibility that the use

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of moringa may be challenged. Some in Haiti view moringa as a food for “poor people,” and are therefore reluctant to be seen eating it (MSPP, 2013), and many others are unaware of its nutritional value (Holla, 2014). This highlights the need for education on the nutritional, environmental, and economic benefits of moringa; indeed the MSPP has recognized this and recommended a promotional campaign targeting the public, decision-makers, and the media (2013). The MSPP also aims to encourage and engage those who have taken initiative with moringa and supporting its diffusion (MSPP, 2013). Several organizations are working to promote its small-scale use including Haiti Reconstruction (haitireconstruction.ning.com), the Haitian Sustainable Development Foundation (sustainablehaiti.org), Signa Haiti (signahaiti.com), and Smallholder Farmers Alliance (smallholderfarmersalliance.org), to name a few. There is a need for assessments of moringa use among the Haitian population and to evaluate outcomes of any moringa-related programs currently running. This research will be necessary to understand pathways between production, consumption, and nutrition outcomes involving moringa in Haiti, as well as potential effectiveness for targeting specific micronutrient deficiencies such as vitamin A and iron.

Food-based Approaches to Addressing Malnutrition The traditional focus in addressing malnutrition in the developing world had been simply providing enough food to prevent hunger, until attention turned to micronutrients and the “hidden hunger” that deficiencies of them bring about (Goplan and Tamber, 2003; Kimura, 2013). This led to the rise of supplementation, fortification, and biofortification as methods of reaching malnourished populations by providing them with quality food, not merely sufficient quantity. Great success was shown in several areas such as vitamin A capsules reducing both vision problems and child mortality and iron supplements helping to reduce incidence of anemia and related effects (Kimura, 2013; Thompson and Amoroso, 2010). Supplementation has saved many lives and abated much human suffering (Thompson and Amoroso, 2010). However, these are sometimes seen as “drug-based” approaches which usually involve imported ‘remedies’ (Goplan and Tamber, 2003; Hillocks, 2011), emphasizing technical interventions above social and political change (Kimura, 2013). While there exists a need for food assistance and nutrition supplements in Haiti for some populations, it is equally urgent to support long-term development of agriculture, infrastructure, and education. As an alternative approach, more and more attention has been given to using locally-available food as a sustainable means to nourish populations and prevent micronutrient deficiencies. A recommendation in the 1992 joint WHO and FAO International Conference on Nutrition, for example, is to ensure food-based strategies are given priority because they are sustainable, “particularly for populations deficient in vitamin A and iron, favoring locally available foods and taking into account local food habits” (FAO/WHO, 1992). In addition, agricultural food-based approaches allow more community ownership and self-reliance, and are often more culturally acceptable while offering an opportunity for marketing surplus for additional income (Hillocks,

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2011). The use of locally-grown moringa would be certainly aligned with this food-based approach to increase dietary diversity and quality. Promoting moringa could help reduce both micro- and macro-nutrient insufficiency while helping to address some of the root causes of malnutrition by providing economic benefits and sustainability. If the people of Haiti were provided the right tools and education in nutrition, agriculture, food processing and marketing, program management and evaluation, as well as government support, the potential of moringa to transform lives would be promising. The fact that the leaves can be ground into a powder opens up doors of opportunity for storage, shipping, and sale of this product. While farmers could use moringa for family food, they could also sell its products (such as leaves, oil, or powder) as a means of economic income. With sufficient market infrastructure, over time, marketing powder to other communities or countries could even be a possibility. In this way, growing moringa can become a cycle of increasing assets. Data from several countries show that well-designed food-based strategies can relatively quickly and sustainably improve the diets of vulnerable populations (Thompson and Amoroso, 2010). Moringa trees could in this way feed not only stomachs, but futures as well.

The Value Home Gardens As there are over a million small-scale farmers in Haiti, examining how moringa may be produced through this vast network would be useful. Additionally, there could be even more potential for home gardens – low-cost small plots close to the home and managed by household members – as a way of improving dietary diversity and reducing malnutrition. Closely related to the use food-based strategies and extensively promoted the FAO and NGO’s in developing countries (Shetty, 2011), home gardens can take a variety of forms. Backyards, containers, rooftops, and the edges of fields can all be made into home gardens producing herbs, fruits, vegetables, and other foods to supplement dietary staples (Berti, Krasevec, and FitzGerald, 2004). This can all be done without involving much additional labor from the farmers since it involves improving the quality (not necessarily quantity) of food produced (Hillocks, 2011).Their success and positive impact on nutrition has been well-documented (Chadha and Oluoch, 2003; Farber and Benade, 2003; Bushamuka et al., 2005; Phillips, Sanghvi, Suarez, McKigney, and Fiedler, 1996). According to Hillocks (2011), home gardens can make a significant contribution to dietary diversity. However, as growing nutritious food doesn’t automatically lead to improved nutrition status of the growers and their families (Hotz, C., personal communication, May 15, 2015), access to the necessary agricultural starting materials and technical support must be combined with education about the value of keeping some of the crops for family consumption. While it is important to ensure commercial potential and market opportunities as an incentive to begin home gardens in the first place, it can be tempting to sell all produce (not just surplus) for income for greater income generation (Hillocks, 2011; Hotz, C., personal communication). It is also essential to particularly support women in home garden initiatives since it is known that women make the majority of family feeding decisions, whereas males tend to see greater value in selling what’s harvested for greater income (Harvest Plus, 2012; Hotz, C., personal

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communication, May 15, 2015). Karanja et al. add that a supportive social network is essential for the success of agricultural production among the rural poor, and that households should be free from “social, institutional, legal, or political barriers to food production and marketing” (2010). One of the longstanding model successes of home gardening to improve nutrition is that of Helen Keller International’s Homestead Food Production (HFP) program introduced over 20 years ago in Bangladesh to help combat vitamin A deficiency (Hillocks, 2011). Since then, the HFP program has spread across Asia and Africa, providing hands-on training to women in gardening, farming, and entrepreneurship, working with community leaders and established local organizations to promote growing and eating leafy green vegetables, among other agricultural products (Helen Keller International, 2014). Impact studies have shown that families involved with HFP have much higher rates of consumption of green leafy vegetables (Hillocks, 2011). Unfortunately this program does not yet exist in Haiti.

Multisectoral Approach

Much of the literature regarding moringa production, promotion, and utilization (as well as parallel studies on other nutritious foods) emphasizes the need to approach this with a multidisciplinary and multisectoral mindset. Nutrition professionals or agricultural experts alone cannot make the social change necessary for uptake of moringa in Haiti or any other setting. As articulated by Upadhaya (2011), nutrition is not a stand-alone field, but rather one that needs to partner with those from health, economics, agriculture, politics, environmental sciences, social sciences, the private sector, and NGO’s to deliver successful policies and programs. The Haitian government as well, through the MSPP report, demonstrates desire to adopt holistic approaches to malnutrition, addressing various determinants of health in a preventative manner, and involving those at the community level for greater effectiveness (MSPP, 2013; Republic of Haiti, 2013).

Social Marketing of Moringa Thurber and Fahey (2009) describe the diffusion of moringa innovation to be a lot like social change, with adoption beginning with innovators (for example, traditional healers) and knowledge spreading to “early adaptors” (such as NGOs) who would spread the word farther and a steady rate of adoption would ensue. One of the next steps for helping moringa to “catch on” in Haiti is to promote it through social marketing and behavior change communication, providing Haitians with the understanding and motivation to grow and consume this ‘wonder-tree.’ Social marketing has proved effective in many global public health initiatives including smoking, contraceptive use, and oral rehydration therapy (Unite for Sight, n.d.). In a systematic review of social marketing in global health conducted by PSI (2014) encompassing 18 years of published studies, results about behavior change are significant. For example, 28 studies show

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social marketing interventions related to child survival significantly increased knowledge, attitudes, and consumption of nutrient-rich food which lead to significant reductions in outcomes such as anemia and diarrhea. Several countries have had success in using social marketing for changing eating behavior in order to reduce nutrient deficiencies. In Micronesia, for example, a creative awareness campaign promoting local food was successful through the use of mass media, print materials, photography, workshops, displays, farmers’ fairs, youth clubs, slogans, and even national postage stamps. In particular, consumption of carotenoid-rich banana varieties increased significantly (Englberger et al., 2011). Also, in Senegal, radio broadcasts and training by dynamic health workers helped increase awareness and consumption of moringa both within and beyond the project’s target area (ECHO, 2007).

Social marketing for opening eyes in Haiti to how valuable moringa is, highlighting international market demand, and thereby increasing perceived value of the tree. This could lead to a greater appreciation and desire for moringa, especially if paired with information about how it can be easily incorporated into traditional meals and improve health without adding cost (Hotz, C., personal communication, May 15, 2015). This could be done through agricultural workshops, media marketing, cooking demos, recipe distribution, and in other ways supporting and furthering the Haiti school promotions as outlined above. A review of healthy food campaigns by Cavicchi et al. (2011) provides some valuable evidence of best practices and recommendations for social marketing for the purposes of nutrition, and could be consulted for direction in Haiti.

Conclusion Haiti is a country facing immense nutrition-related challenges, but which also holds great potential for overcoming those challenges through its own natural resources such as the powerful Moringa olefiera tree. Growing, consuming, and selling moringa could empower Haitians with a means of income as well as food security. This sustainable, doubly-strong strategy could strengthen not only bodies, but also individual decision-making power, community capacity, the Haitian economy, and ultimately help provide a bright and future for Haitians. Steps towards the promotion of moringa will provide a large return on investment.

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