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President Obama's ambitious Global Health Initiative — announced to a receptive international community in 2009 — is faltering as budget constraints and shaky implementation limit the impact of the multibillion-dollar program.

GHI targets chronic malnutrition in Guatemala

'Invisible killer' stunts Guate's youth.

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