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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.

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.”

Gender wars

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.