Although most of Guatemala's children have enough food to eat, many are not receiving the right kind of food. Samuel Loewenberg reports on the country's growing crisis of chronic malnutrition.
In the clean, toy-filled interior of a clinic in Chiquimula, a 9-year-old girl appears to be frowning. Her name is Domitila, and her muscles are too weak to form a smile (see webvideo
). Her body is fragile: arms and legs wasted, patches of hair missing, the veins in her legs forming a black web-like pattern that shows through her delicate skin.
Domitila is one of about a dozen children in the Bethania rehabilitation clinic in the far-eastern town of Jocotan, near to the Honduran border. In an adjoining room, a 3-year-old boy, Israel, cannot even support his own weight. He has been placed in a walker, on which he is sprawled. He tries several times to raise himself, but cannot lift his head. A pair of 4-month-old babies, twins, lie in their cribs crying, both emaciated. Across the room, a nurse gently drops food into the mouth of an infant so small it barely looks human.
The cases of Israel, Domitila, and the other children here are the extreme edge of the hunger crisis in Guatemala, which has some of the worst rates of chronic malnutrition in the world. These children in the clinic are severely malnourished, many have kwashiorkor. Although these children are still the exception, chronic malnutrition can tip over to catastrophe, especially now, in the wake of the global food, climate, and financial crises. Unlike the more commonly known wasting in severe malnutrition, with chronic malnutrition, the problem is not a lack of food, but a lack of the right kind of food, with enough protein and micronutrients to keep children healthy.
“The chronic malnutrition could at any moment turn acute with the current economic crisis”, said Wayne Nilsestuen, who heads the US Agency for International Development's (USAID) office in Guatemala.
Half the children in Guatemala have chronic malnutrition. In some areas the rate is as high as 90%. This is startling, because in terms of gross domestic product, Guatemala is a fairly prosperous country. Yet the rates of stunting here are on par with failed states like Haiti—the national census of height in 2008 found that nearly half of children younger than 5 years are stunted. Research published in The Lancet last year shows that children who have chronic malnutrition face not only stunted growth but also a diminished mental capacity and a substantial decrease in earning power.
Guatemala has stark divisions between its rich and poor communities. The populations affected by malnutrition are largely the Indigenous Mayan communities that make up most of the country's rural farmers, mostly sharecroppers, who have twice the rates of stunting of the non-Indigenous population. Most of the hunger hotspots also track with the places in which the civil war was most fierce, like the province of Quiché in the highlands. This was not by mistake. “Budgets were shifted to keep some populations less developed”, said Andrés Botrán, who pioneered some of his country's anti-hunger programmes in the last government. “For us it is a national shame.”
It is often said that Guatemala is really two countries in one, divided between the few rich and the many poor. It is among the most unequal countries in the world, with 20% of the population receiving 60% of the income. An extremely low tax base means that the government has very little to work with to alleviate the poverty. Around 6 million of the country's population of 14 million live in poverty, and nearly half of those in extreme poverty.
Botrán himself is one of Guatemala's ruling elite, the scion of the powerful rum dynasty that bears his name. It was Botrán who took up the issue in the early part of the decade as an adviser to the Óscar Berger government, which was more conservative than the one currently in power. Botrán admits that he came across the malnutrition issue almost by mistake, which occurred to him as a ripe political issue while he was helping the campaign. He says that when his assistant first presented him with data that half his country's children were malnourished, he did not believe it and accused him of making a mistake. But the numbers were right.
9-year-old Domitila at the Bethania rehabilitation centre in Chiquimula, Guatemala
Parents and children queue to see a doctor at a health clinic in the Chiquimula region
“Malnutrition does not get any headlines unless there is the picture, the money shot”, such as a child with a distended belly and flies buzzing around, he said.
After Berger won the election in 2003, Botrán was appointed to a head an agency focusing on malnutrition. “One of our main issues was to communicate the reality of food insecurity in Guatemala” to the political and business elite that ran the country, to explain that the malnutrition threatened to destabilise the economy. “Our democracy was not safe, our society was becoming more and more frail”, he said.
The reasons for chronic malnutrition in Guatemala are attributable to several factors: the stark income inequality; a lack of education; the increased price of beans and eggs, which are one of the only sources of protein for villagers; poor, or in some cases non-existent, infrastructure, meaning no electricity or running water, and certainly no clean water: so diarrhoea is a major factor. And Guatemala remains a highly dysfunctional society, still badly damaged by the 36-year-old civil war that wiped out an estimated 200 000 people, most of them civilians. There are also 24 different Indigenous groups, each with their own language; many of whom speak only rudimentary Spanish.
Underlying this situation is poverty. The malnutrition, which is hidden from Guatemala's wealthy urban populace, happens in places like the mountainous region of Quiché. 80% of the population lives on under US$2 a day, according to Claudia Nieves of Save the Children USA. In the mountain town of Xobor, villagers live in huts with dirt floors and tin roofs, with little patches of land out back to grow corn or lettuce or a cassava-type root. Some families are lucky enough to have chicken pens or the occasional pig, but the animal's products are usually sold rather than eaten, and even eggs are a luxury.
A visit to a village in Chiquimula illustrates the problem. In a two-room hut at the bottom of a hill, Maria Boton Canto prepares lunch for her five children. She works over a wood fired stove, rhythmically patting her hands to make dozens of corn tortillas, accompanied by a small bowl of pasta and a spoonful of refried beans (in the wake of rising food costs, important sources of protein like beans and eggs only come a few times a week). Her youngest daughter is being treated for malnourishment, and the other children appeared to be stunted as well. They wolf down their tortillas and drink a soft drink to fill their stomachs.
“Intra-uterine malnutrition is where the problem starts”, said Nieves. She also noted that in the period before Guatemala's civil war, which began around 1960, the country had a sanitation corps and hygiene programmes. That has all gone now. Dirty water and nearly non-existent sanitation in many areas of the country ensure that disease and malnutrition remain rampant.
If he had more money, “there is no doubt I would put it into water and sanitation”, said Juan Aguilar, the current head of Guatemala's nutrition and food security agency.
While the very rich reap the benefits of Guatemala's agricultural bounty (the top 20% of the population take two-thirds of the country's income), they give little back. Tax revenues in Guatemala are among the very lowest in Latin America, smaller even than its poorer neighbours. “There's not enough money for the state to perform its functions”, said USAID's Nilsestuen.
Among Latin American countries, Guatemala is the only one to have failed to decrease its malnutrition over the past decade—even countries with worse income inequality, like Brazil, or ones that are poorer, like Honduras and Nicaragua, have had much bigger successes in addressing the problem. So far, in Guatemala, efforts are just going towards treating the symptoms. It is not enough.
“In the broader sense this is really a problem of political will”, said John Hoddinott, a senior research fellow at the International Food Policy Research Institute in Washington, DC, USA, who has worked on malnutrition issues in Guatemala since the 1960s.
Per head income figures in Guatemala are four or five times higher than in Haiti—yet the two nations have roughly similar rates of stunting, said Hoddinott.
In general, poor people themselves do not realise that stunting is an issue because the problem is so widespread. The rates of malnutrition are twice as bad for the Indigenous population as they are for non-Indigenous.
That is a problem of distribution of resources. The Indigenous parts of the country are so much poorer and so isolated that most people are unaware of their situation. “If you go to a place where everybody is stunted, nobody has a reference group”, said Hoddinott.
In the rehabilitation clinic in Jocotan, 9-year-old Domitila sits listlessly on a bench. Some of the younger children are rambunctious, running around with toys despite their wasted state.
At the clinic, funded by a Belgian charity, doctor Evelin Nufio explains that Domitila's family is extremely poor, as is her whole village, and that when she came to the clinic she was in even worse shape than now.
She has brothers and sisters, some of whom are in even worse states, but she was the one sent to the clinic because she has a foreign sponsor. That money goes to feed the whole family, and apparently her parents were concerned that in her underfed state, if they sent a photo of her to the sponsors they would not receive any more money, so they sent her to the clinic to get healthy. It is a cycle that is likely to be repeated.
Hunger is a way of life in the arid region of Chiquimula. Farmers grow beans and corn and not much else. Water is scarce, often many kilometres from homes. By March, the production of food diminishes and the hunger season starts. The two clinics for severely malnourished children around here typically get around 15 patients at a time, who stay for about 3 weeks. Nufio explains that the clinic is careful not to give the children special foods, because when they return home those will no longer be available, so instead the children are rehabilitated on such staple items as beans, eggs, and tortillas.
The symptoms of severe malnutrition occur at the most fundamental level. For some children, their normally jet black hair turns blond due to vitamin deficiency. In more severe cases, the hair falls out in patches. The skin may peel and darken. Most confusingly, many of the children look puffy, almost obese. This is because they are retaining liquid and their internal organs are not working properly, which may include increased liver size, said Juan Manuel Mejia Terranza, a doctor at the Nutritional Recuperation Center of Jocotan.
The government, working with the World Food Programme (WFP), has a programme to distribute supplementary food to undernourished children. The supplement, called VitaCereal, arrives once a month at the far-flung villages. The monthly distributions of the enriched corn-soya blend are an event for the remote communities. It also the only time that the children see a doctor.
People come from kilometres around to receive the food. On one scorching day high in the mountains in the village of Pelillo Negro, a mother and her three children indicated that they had hiked all the way across a valley and far up the mountain for nearly 2 hours to come for the food.
At the town community centre, the gathered mothers crowded around with their infants and toddlers, waiting for food and to see the doctor.
First, the babies must be weighed on a portable hanging scale and measured with a collapsable device. The children howl as they are placed in the slings or forced to stretch their legs out by a volunteer. But most worrying are the handful of children too listless to respond, who instead simply lie there, too weak to protest. In some cases, the children are deemed by the doctor to be severely malnourished.
Inside the clinic, doctor Melvin Omar Tomillos tries to convince a family to send their daughter to the rehabilitation clinic. The little girl weighs only 9 kg, making her about 5 kg underweight for her age of 2 years and 8 months. “The girl, if she continues to lose a lot of weight, her defence system will diminish. Her defences are so low that a small cold could become pneumonia and she could die”, he said.
A health worker explains the preparation of VitaCereal to a village in Chiquimula
But the parents are resistant. The mother would have to go with the girl to take care of her at the clinic, and the father says that she is needed to take care of the house and the children while he is at work.
It is a frustrating scene. The man says he only earns about 25 queztales a day ($3), and so cannot provide for his family. The girl, Yolanda Perez, has been losing weight. The family has been getting the VitaCereal for the past 3 months, but it is being divided between all four children, said Lida Escobar, a WFP field worker. So instead of lasting a month as it is supposed to, it is gone in a week. Also, the mother dilutes the mixture too much, a common problem that undermines the feeding programme.
The mother does not seem to know what to do: “At 1 year she escaped death, for 2 nights she was unconscious, she wouldn't breastfeed”, she says.
“So the person who has least access to the VitaCereal is the girl in the programme”, says Escobar. “She's consuming the least and that's why she's losing weight.” The father does not earn enough money, “so he cannot provide for his family. That is why this is going on”.
Funds for SL to travel to Guatemala were provided by the Pulitzer Center for Crisis Reporting