CAJOLA, Guatemala — High in the mountains, a narrow and practically impassable mud trail leads to the dirt-floor shack where Isabella Hernandez is rhythmically patting tortillas, the main source of sustenance for her nine children.
A wisp of a woman, clothed in her community’s signature colorful dress, Hernandez is illiterate and a single mother who ekes out her family’s existence on less than $1 a day. Nearly 60 percent of this mostly indigenous Mayan town lives in such extreme poverty.
On this day a health worker had come to weigh and measure the children while delivering a nutritional supplement for the poor. A veteran in the hunger wars, Julissa Garcia knew what she would find. Sure enough, they were not only underweight but about half a foot shorter than the minimum recommended height for their age. Known as stunting, such a height deficit is a key indicator of chronic malnutrition.
“Almost all the kids here are malnourished,” said Garcia, who has pioneered a support group for Cajola mothers with stunted children.
It is communities like these that President Barack Obama’s Global Health Initiative (GHI) is focusing on in Guatemala. Slow in its implementation and hampered by little new money, GHI is targeting Mayan women and children in the mostly indigenous Western Highlands, a mountainous area with a single maize harvest per year. The strategy’s cornerstone is reducing one of the highest rates of chronic malnutrition in the world. According to the United Nations Children’s Fund, only Afghanistan and Yemen fare worse. Half of all Guatemalan children under five are stunted and in the Western Highlands, it's seven out of 10.
Called the “invisible killer,” chronic malnutrition isn’t necessarily a lack of food but a shortage of the right kind. Faced with insufficient nutrients, especially protein, the body compensates by simply stopping to grow. More importantly, brain capacity and productivity is reduced by as much as 40 percent. That can’t be recouped.
Such a lack of nutrients is obvious in Hernandez’s small shack. Lunch is their highlight, when the children fall silent as they shovel down tortillas flavored by salt, potatoes, and plants their mother picked in the fields. They eat while they can. Their bellies will predominantly rely on hot maize drinks for the rest of the day.
There are no beans or eggs. Meat is a rare luxury.
Garcia gasped when she saw how the three middle boys, each more than a year apart, essentially weigh and measure the same — at or below the minimum recommended amount for the youngest. It’s difficult, however, to gauge the effects of stunting on their cognitive development. None of the Hernandez children have ever attended school and all are illiterate, most speaking mainly their indigenous language of Mam.
An overwhelming problem
The magnitude of the problem is stunning, as are the consequences. Such children are particularly susceptible to diarrhea and other illnesses. Chronic malnutrition is the single biggest contributor to the deaths of children under five. As concerning is the effect on their brains, thus the consequence on Guatemala itself.
“These children have been lost,” said Dr. Baudilio Lopez, a project development specialist at the Guatemala City office for the U.S. Agency for International Development (USAID.) “They can’t learn, they can’t be productive.”
GHI, which Obama unveiled two years ago, has been slow to implement, according to critics. And, due to the U.S.’s own budget woes, it has been hampered by less funding than expected. In Guatemala, USAID received basically the same level of funding, about $14 million, over the past two years, and just over $16 million for FY 2011. Cuts are likely ahead, given Washington’s budget crisis.
Nutrition efforts will also benefit from funding to Obama’s global food security initiative, which channeled about $25 million annually into Guatemala over the past two years.
The amount of funding pales in comparison to the seven other GHI focus countries. Guatemala’s GHI program receives by far the smallest amount of aid, just 1/37th received by Kenya, which has a $600 million GHI budget.
Still, officials at USAID and the Centers for Disease Control and Prevention, GHI’s two main implementing actors here, remain buoyant. They say the tightened focus on specific global health issues in a targeted geographic area combined with better collaboration among U.S. agencies is revolutionary.
For their part, Guatemalan health officials say they have never worked so closely with U.S. agencies.
"It's the first time that U.S. agencies sat at a table with the Ministry of Health to jointly plan" health strategies, said Dr. Edgar Gonzalez, who is heading GHI efforts for the Ministry of Health.
The initiative faces challenging obstacles. The percentage of Guatemala’s total population that is chronically malnourished has barely budged for more than a decade, despite efforts to reduce it. Guatemala is in many respects a tale of two countries. It is ranked 13th among the nations with the greatest level of income inequality, according to the United Nations Development Program. A semi-feudal society, 2 percent of the population owns about 70 percent of productive land. And though Guatemala’s average per capita income is $2,700, half of its 14 million residents live on less than $2 a day.
Most of the poor work as sharecroppers and are vulnerable to effects of global warming and natural disasters. As one of the top 10 countries most affected by both, Guatemala over the past two years experienced the heaviest rains in decades and severe drought as global food prices increased and remittances from the U.S. dropped.
Moreover, Guatemala’s notoriously weak government hasn’t made many inroads in addressing the problem, partly owing to one of the lowest tax collection rates in the world and a history of corruption. The impending presidential elections will likely overhaul government for the fourth time since 1996 making continuity in programs yet another challenge.
The plight of the Mayans
Most affected by malnutrition are the Mayans, who make up 40 percent of the country and have twice the rate of stunting of the non-indigenous. All poor health indicators basically double among the indigenous. They have lived in entrenched exclusion for decades, since before a leftist government effort at social reform, particularly land redistribution, sparked a U.S.-backed military coup in 1954 and catapulted the country into decades of civil war. More than 200,000, the majority indigenous civilians, were killed in one of Latin America’s most violent armed conflicts.
The 1996 peace accords made some advances, but more than 70 percent of Mayans continue to live in poverty. Many are geographically isolated, pushed into remote areas either fleeing persecution or seeking space to farm. They predominantly speak one of 24 Mayan languages. High illiteracy rates and traditional Mayan beliefs further complicate health efforts.
El Quiche is one of Guatemala’s poorest and most populous states, indelibly stained by the civil war. Of the indigenous civilians killed during the civil war, eighty-three percent of all identifiable victims were Mayans from this mountainous region. There’s only one factory here and, as one of the most food insecure regions in the country, agricultural yields are slim.
Seventy percent of children under five are chronically malnourished. Families migrate between the sugar and coffee harvest seasons to survive, but the economic crisis has meant less work. It is here that USAID, through its implementing partner Save the Children, has overseen a promising program in combating malnutrition. Similar efforts are occurring across the Western Highlands.
Faced with finite resources, protein and vegetable consumption is virtually non-existent among Mayan families. More than a fifth of all Guatemalan pregnant mothers have anemia, which is caused by a lack of iron and increases the risk of hemorrhage and the chances that infants will be born underweight and suffer cognitive impairment.
For years, aid workers concentrated mainly on food distribution and still, in Quiche, a majority of families receive donated beans and rice to help them survive.
In 2006, Save the Children surveyed their target communities here and found, to their surprise, that they didn’t recognize malnutrition as a problem. Their concerns were a new road or clean water, a school. This is a national phenomenon. In a study conducted last year, less than 1 percent of Guatemalans, who tend to believe they’re naturally short, identified malnutrition as a concern. Stunting, however, is not genetic. A World Bank study found Mayans in southern Mexico are taller than in Guatemala. Those raised in the United States reach normal heights.
In Quiche, Save the Children devised a strategy to tackle chronic malnutrition on a broader scale: education on what foods to eat, assistance with providing those foods, and most importantly, the election of community leaders to head the process, encouraging ownership to make it self-sustainable. In Chacaguex, for instance, Antonio Acabel was given several goats. With milk high in protein, goats also require far less land and food than cattle. As his herd multiplies, Acabel spreads them among the community, prioritizing families with young children.
“Before,” Acabel said, “no one drank milk because it’s too expensive.”
As the local farm leader, Acabel was trained how to more efficiently farm maize and which plants within his reach are high in protein. Instead of fertilizer, he uses goat manure – longer-lasting, better for his crops, and saving him $20 every three months. Today he hosts community workshops on better farming practices. His tiny vegetable garden is meticulously organized with each plant carefully labeled – proof of a man proud of and grateful for his work.
Such a simple premise, really: supply a bit of capital and show how to use it.
“It changed my life and that of the community,” Acabel said. “Before we didn’t have anything.”
Another initiative is a rigorous training process for “mother leaders” in the community. A liaison between health care workers and indigenous mothers, they teach women how to cook high-protein plants within their reach. Using bright diagrams of women in traditional dress, they show what kinds of food to provide children, in what quantities, and when. They urge the necessity of exclusive breast-feeding up to sixth months and how to combine it with food after that – key in preventing chronic malnutrition. Only half of Guatemalan infants under six months are solely breastfed.
“Before we didn’t know these things,” said Alma Cecilia Real Ajcot, 27, a mother leader who oversees food distribution. “Now that they have taught us how it is, we can do it.”
The concept of mother leaders has been wildly successful. They are friends and neighbors, inspiring trust, and familiar with traditional Mayan beliefs that might cause or worsen health problems. The phenomenon of mal ojos, for example, the idea that you can get sick if someone gives you a bad look, means mothers often only seek medical attention once it’s too late.
Most importantly, the women speak the same language.
“Sometimes we can’t even pronounce their names correctly,” said Marta Picasa, a nurse at a tiny health center outside of Quetzeltenango. “With us they will not have the same level of confidence.”
In Totonicapan, Guatemala’s poorest region, where 82 percent of all children under five are malnourished, USAID is funding a similar program aimed at educating Mayan men, who control most family decisions. Women, for instance, can’t seek medical attention without spousal permission – a critical contributor to Guatemala’s high maternal death rates. Men may also not understand or support why their wife wants to buy vegetables, say, instead of corn or rice.
They are taught the necessity of birth control as experts say chronic malnutrition and poor family planning are closely linked Indigenous families in some regions average 10 children but support them on an income barely enough for two. Malnourished mothers give birth to malnourished babies. Though Guatemalan’s use of birth control has doubled to 50 percent, many indigenous women still use it secretively, as men tend to equate contraceptives with infidelity.
Yet behavioral change can only accomplish so much if poor families can’t buy food. In conjunction with Feed the Future, Obama’s global food security initiative, officials said they would continue linking rural farmers directly to bigger markets to improve their income. Near the tourist attraction of Lake Atitlan, for example, USAID helped indigenous farmers form an agricultural cooperative, building a storage shed to prepare their vegetables. Before, these farmers worked alone and hawked their wares in the village market, which were purchased by middlemen, transported to Guatemala City, and sold to international vendors. Now the farmers sell directly to Wal-Mart.
Officials said they would also expand on programs encouraging employment for Mayan women. An extra dollar per month in a Guatemalan mother's hands achieves the same weight gain in a child as roughly 14 times more earned by the father, according to the Population Council, an international non-profit. USAID is also teaching communities how to organize to demand potable water from local governments. In rural communities, access to safe drinking water is scarce.
Making do with scarce resources, the success of GHI depends to a large degree on Guatemala’s Ministry of Health. One of the most fragile arms of a weak government, its slow collapse has been the subject of continuous media reports. Many health workers haven’t been paid in months and in some areas medical supplies simply stopped arriving. Patients transported by ambulance must often pay their own gas. Part of the problem is that its budget has been slashed to fund a conditional cash transfer program aimed at poor mothers, a cornerstone of the government strategy to combat malnutrition. The program has been widely criticized for the lack of oversight and transparency. Guatemala’s upcoming presidential elections will likely also affect GHI implementation.
In the dirt-floor shacks of Cajola, the scramble for survival continues. One of the biggest sources of help to Hernandez have been Peace Corps volunteers, who built her a stove so she no longer cooks on open fire. At 37, Hernandez’s breezy humor lights up her delicate features. Two months ago, she nearly died after hemorrhaging during her last pregnancy, arriving at the emergency room bruised from a fight with her ex-husband.
Like their community, the lives of the Hernandez family are isolated. None attend school because, while it’s free, the mother said the extras on books or pencils would break her budget. So the effects of their malnutrition remain unknown, likely forever.
Her spouse pays her $25 a month though it varies depending on his drinking. She relies on handouts, water from her neighbor’s well and nutritional supplements from the health center. She has a small maize crop. Life here continues like it always has, with the same limited future. Recently, however, Hernandez saved up money to buy two piglets, which she hopes to breed.
“I don’t have the capital right now,” she said in her native language of Mam. “But I would like a good business with my pigs. That way I can maintain my kids.”
She smiled. Then the youngest cried, so she sat down to breastfeed, leaving her teenage daughter in charge of lunch – tortillas, the same as yesterday, all the days before that, and what tomorrow would bring.
Funding for this project is provided by the Henry J. Kaiser Family Foundation as part of its U.S. Global Health Policy program.