BRIGHT Study photography 2017. Keneba, the Gambia
Baby steps: a Gambian child wearing a headband that shines light into the brain and measures colour changes which reflect brain activity
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Baby Fatima is watching her siblings play in the compound where she lives in a small village in Gambia. Her family rely on subsistence farming but rainfall has been low this year and the harvest is poor. Food will be scarce and what is available will not contain the balanced diet she needs. This means Fatima will not grow as she should, she will be more susceptible to infections and her brain will suffer. Fatima’s mother did not have enough to eat as a child, and if her daughter survives to have children of her own, Fatima is also likely to give birth to a malnourished baby, perpetuating the cycle from one generation to the next.

Assessing the development of children like Fatima has up to now has been limited to measuring physical growth — but new brain scanning techniques may be able to spot problems and pinpoint effective interventions much earlier.

According to a joint Unicef/World Health Organisation/World Bank 2018 report, more than 150m children under the age of 5 are shorter than normal for their age or stunted as doctors call the condition. Lack of proper nutrition not only impairs physical growth, it threatens what cannot be seen — a child’s mental development.

Ninety per cent of the brain grows in the first thousand days of a child’s life. More than a million neural connections are formed every second. The nutrients, care and stimulation that infants receive during this crucial phase of brain development will determine their ability to learn and how they behave. Other problems caused by extreme poverty — diarrhoea, poor sanitation and lack of healthcare can also have a devastating effect on the growing brain and prevent children from achieving their full potential when they grow up. A report published in the medical journal PLoS Medicine in 2016 estimated that one-third of the world’s children living in low- and middle-income countries, fail to reach basic milestones in their cognitive or socioemotional development. Deficiencies in communication skills and memory can have a significant impact on their performance at school, leading to less well-paid jobs and lower economic productivity as adults. This in turn hurts the economies of their countries.

Global health funders and policymakers are beginning to respond to this crisis. Grand Challenges Canada, a government-backed fund, has invested C$53.5m in the Saving Brains initiative to fund innovative projects combining health, nutrition and nurturing for the poorest children. “We are committed to supporting the early childhood development of the next generation’s human capital,” says co-chief executive Dr Karlee Silver. “People will be better equipped to solve the challenges that lock individuals, communities, and societies in poverty.”

For decades the most effective way of understanding brain development was to chart what a child can do as they reach various ages. Behavioural tests have been created to establish when infants can roll, sit, stand, look for a hidden object, and express themselves and have formed the mainstay of research. Yet these are not necessarily fit for purpose in poorer countries.

The current tests, mostly formulated in the US, are not adapted to different childhood environments. For example, the ability to climb stairs is included in many tests, but toddlers in rural Africa do not come across a lot of staircases. A more relevant test might check they have the strength and co-ordination to cling on to their mother’s backs while being carried in a scarf in the traditional manner. Moreover, the tests’ value has also been limited because until now they have only been conducted when a child’s action can be observed — not earlier when the most rapid changes in the brain are taking place.

This could change, thanks to a breakthrough in portable brain scanning. A new technique called functional near infrared spectroscopy (fNIRS) uses light to show oxygen distribution in the brain. This detects an infant’s brain activity while exposed to culturally appropriate stimuli — for example Gambian nursery rhymes that would mean something to a child like Fatima. This information can then be used to reveal which parts of the brain are more vulnerable to damage than others.

fNIRS technology is inexpensive, easy to set up and requires minimal training. In February 2012, with funding from the Bill & Melinda Gates Foundation, physicists and neurodevelopmental psychologists from University College London and Birkbeck, University of London transported an fNIRS system to a field station in Gambia run by the UK Medical Research Council. Within a few hours the team had captured the brain of a four-month-old child, thought to be the first image of brain function from an African baby.

The BRIGHT (Brain Imaging for Global Health) project is currently imaging 200 infants from birth to their second birthday in Gambia including baby Fatima.

This five-year study, to be accompanied by parallel exercises in Bangladesh and India, will track brain function at various ages and will show how malnutrition and poverty affect the growing brain. Researchers will then be able to use this data to establish which nutritional supplements are needed to protect the brain. This may include giving mothers food so that so that they are well-nourished enough to breastfeed and give their babies the best start in life. By looking at babies’ brains in the first months of life, the team will be able to understand how best to prevent long-term cognitive impairment before it becomes irreversible.

This academic work takes a further step towards protecting the world’s most deprived children and allowing their true human capital to be unlocked.

The writer is the principal investigator at the BRIGHT project and professor of medical physics at University College London

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The World Bank’s new Human Capital Index allows countries to benchmark themselves globally on the health and education investments needed to fulfil their potential. Plus: how brain scans help poor children; Rwanda’s compulsory health system; and what needs fixing in the Asian Tigers’ education system.

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