Tuesday, March 28, 2017

Tom's Visit, Part 1: A Guatemalan Thanksgiving

Text by Tom Kemple

Tom Kemple is a sociology professor at the University of British Columbia and a long-term friend of Pop Wuj. With his colleague Sylvia Berryman in Philosophy, he has been bringing groups of students to study in Guatemala since the summer of 2010. This past November and December he spent 5 weeks studying Spanish, building stoves, helping out in the Pop Wuj Clinic and Nutrition Program, and having fun at the Family Support Center. What follows are some writings from his trip created in the course of his research project on university fieldshools and study abroad programs, titled “Global Citizenship at Home and Abroad.”  We hope you enjoy Tom's stories and insights as much as we enjoyed having him back at Pop Wuj.

Dr. Herman, Nurse Luby, and I arrived around 8:30 a.m. on Thursday (American Thanksgiving) by microbus in Llano del Pinal, the indigenous village near Xela that I’ve been visiting a few times a week to build safe stoves or to play with the kids in the Family Support Centre. I had been talking about my experiences in this village with my teachers in Spanish classes, and reading about its fascinating history in Greg Grandin’s The Blood of Guatemala: A History of Race and Nation. Some of the fist massacres in the early years of the conquest took place here; communal land was commodified and divided up into plots among families during the liberal reforms of the late 19th century; and it was a centre of resistance in the early 1950s when a leader from this community, an illiterate peasant named Valentin Coyoy Cruz, was murdered, probably by the indigenous elites from the city who were against the radical agrarian reforms of the socialist-leaning government.

To an outsider like me the village seems quiet, poor, and friendly, and yet it also holds answers to many of the questions I brought with me to Guatemala. I have been learning about how the problems which are most evident here – extreme poverty, precarious health, ignorance, adolescent pregnancy, and chronic malnutrition – have their roots in both the recent and the distant past.

I had volunteered to help out with Pop Wuj’s Nutrition Program for children under 3 years of age. When Luby asked me whether I was a doctor or a medical student, as are most gringos at the school these days, I told her ‘Doctor de Sociologia.’ When I later made the same joke to Carmen, who oversees all the social projects, she also laughed: “Then give me a pill for a good society, please!"

It seemed incredible that all the boxes we were unloading were just for our day’s work, and I was ever more surprised when we started pulling computers and wires out of them. Dr. Herman led me to a room filled with women and children (the mother and little girl whose stove we were building yesterday smiled shyly at me as we passed) and then explained our first task: help the mothers place their babies in the white sheet under the scale while he checked their weight, and then hold their heads still on the table while he measured their height and called out the numbers to Victoria behind the laptop at the end of the table. This part of the morning was the most overwhelming: kids are adorable at any age (and often annoying!), but passing these 24 little lives through our hands was heartwrenching. Most were under 2, and several just a few months old; some peered sweetly and trustingly at us as we lowered them gently into the sheet or stretched them out onto the table; others put up a fight, cried out in fear, gave us a suspicious look, or stared at us angrily.

A participant and his mother in La Victoria in February.
(Photo by Emily Rempel)

For each child under 2 we also took a cranium measurement (perimetro cefálico), which reminded me of the anthropometric practice of western ethnologists among so-called ‘savages’ in the late 19th century. Even the most resistant babies calmed down for this part, and yet it still seemed cruel to fit these tiny human beings in their first years of life into a numerical grid of weights and measures — ‘estatura’/‘edad’/‘peso’/‘genero’ (height/age/weight/gender). Dr. Herman lightened the mood with the occasional laugh at a struggling child, a few kind instructions to the mother, or a casual remark to me about a child who was especially tiny or large. As they looked up at us as if to pose a question or issue a command, I could hardly concentrate on the numbers being recorded in the computer (ranging from around 13.99pds and 63cm to 22.51plds and 81cm, as I later noted). When I described these experiences over email to my colleague Sylvia, she pointed out to me that this commitment to record keeping is not just a bureaucratic protocol done for its own sake, but also a way of showing care, not cutting corners, and respectfully enacting a basic right.

As we moved to the computers in the room across the corridor, I mused to myself that in a sense our next task would involve flattening out each of these vulnerable bodies onto a two-dimensional graph. Dr. Herman patiently instructed me on how to navigate between the plastic charts plotting standard deviations and the data just entered into the computer (translated into English according the program that the Timmy Global Health shares with Pop Wuj, and using a mix of both metric and standard measures). Meanwhile, the mothers and their children played together on a finger-painting project and listened to Carmen speak about the importance of nutrition, all to the tune of a Brahms waltz blasting from a pair of speakers behind us.

Our final task was to note any changes in height and weight from last month’s visit, which Dr. Herman used for his diagnoses and prescriptions, and which I dutifully entered into the computer. As the babies in front of us laughed, cried, and played with their mothers in Quiché and Spanish, I conjured up a picture of them being ‘institutionally captured’ (in my sociological jargon) by a medical system projecting out from our computer screens and communicating to us in English. But I could also see that the Nutrition Program included an important educational component, a ritual element of play and socialization, and even a kind of musical therapy.

Medical Spanish Program students do a check-up with Jesler Juanito and his mother Doña Victoria in La Victoria in February.  Jesler Juanito suffered a serious health setback last year with an outbreak of rotavirus and has made excellent proress since then. (Photo by Emily Rempel)

The diagnoses were alarming and sad, nearly all falling into the ‘Stunting’ classification (‘chronic’ or ‘severe’); most suffering from ‘Malnutrition’ (many ‘chronic’, several ‘severe'); and a few ‘Underweight’ (‘chronic’) as well. At Dr Herman’s seminar a couple weeks later, I found out that 100% of the families in Llanos who benefit from the Nutrition Program live in ‘extreme poverty’, officially defined as living under a dollar per person per day. (50% of Guatemalan children are malnourished, and 1.2 to 3.6% of these are acutely malnourished).

Nearly every prescription followed a similar pattern, varying according to severity and age: NutriButter™ supplement 3 packs everyday for 21 days (I later learned that the other supplements, Plumpy Nut and Maní, were out of stock that day); 23 mg pills of Zinc Oxide once a day for 21 days; Incaparina everyday (a thick drink that tastes like corn, served warm to everyone that morning with a banana as a snack). This data then made its way to Nurse Luby’s laptop at the table next to us, where several girls from the community filled the packages for the mothers to take home. With still more work to do, Dr. Herman went on to call out the numbers of patients (written on the back of their hands) for additional consultations, beginning with the twin boys who had arrived late with their beautiful mother, one large and lively the other thin and lethargic, followed by several children with colds, stomach aches, and other intestinal ailments (7 in all). In Dr. Herman’s seminar a few weeks later, I was cheered to learn how the Nutrition Program improves the weight and height of most of the children who participate in it, and prevents acute malnutrition in all of them.

As I rode back with Carmen to the school for my 2 p.m. Spanish class, I thought about the irony that today was American Thanksgiving, which I remember from my childhood as a day spent among family, overeating to my heart’s content. A morning of weighing and measuring malnourished babies and prescribing Nutri Butter™ and Incaparina to indigenous families seemed worlds away from stories of Pilgrims and Indians eating turkey. That evening I went as usual to the weekly dinner at the school, a potluck featuring a huge variety of delicious dishes, with dessert. Sharing a sumptuous meal with teachers, students, and friends of the school made me feel especially thankful to be here.

Thursday, March 23, 2017

Effects of Malnutrition

Text by Emily Rempel
Images as noted

Throughout March, Pop Wuj is spotlighting our Nutrition Program and its mission to create lifelong opportunities for Guatemalans via treatment of early childhood malnutrition.

¡Gracias por su apoyo! Thank you for your support!

If you were to ask one of our many doctors or medical students about the impacts of malnutrition, you would likely receive a flood of information about z-scores, development markers, and a whole slew of acronyms that, if you’re like me, you’d have to Google. I, obviously, am not a doctor, nor a medical student, nor have I even taken a single science class in the last four years. So consider the following a layperson’s explanation of the short-term and long-term impacts of malnutrition, with a bit of a human rights flair.

In 2015 the international community adopted a set of goals aimed at ending poverty, protecting the planet, and ensuring prosperity for all as part of a new sustainable development agenda. These goals are called the Sustainable Development Goals, or more colloquially, the Global Goals.
Image from UN News Centre

#2 of the Global Goals is: Zero Hunger. By 2030, we have committed to ending hunger, achieving food security and improved nutrition, and promoting sustainable agriculture.

Image from GlobalGoals.org

Why is this so important?

Globally, 1 in 9 people in the world today are undernourished.[i] Nearly half (45%) of deaths in children under 5 are due to poor nutrition.[ii] Guatemala has one of the highest rates of chronic malnutrition in the world (at 47%) and the highest rate of child stunting (low height for age) in the Americas, estimated at 47% at birth, 53% at three months of age, and 56% at six months.[iii] Those most severely affected by chronic malnutrition in Guatemala are indigenous women and children. Mary, our Environmental Projects Coordinator, talked about why these numbers are so high and why they affect whom they affect in her latest blog post. Now we’re going to talk about what these numbers and effects mean.

In the short-term:

Many of the short-term effects of malnutrition are obvious and visible; namely, stunting (low height for age), wasting (low weight for height), and children who are underweight (low weight for age).[iv] It has also been identified as a major cause of reduced head circumference.[v] One of the greatest immediate threats caused by malnutrition is its impact on the immune system. Malnourishment can greatly compromise a child's immune system, making them more susceptible to infectious diseases. This is particularly troubling in the communities in which we work, where there are often poor sanitary practices and increased exposure to animal feces, unclean water, and other forms of contamination. There is a reciprocal relationship between malnutrition and infections, which is compounded by poverty: malnutrition increases susceptibility to infections while, at the same time, infections worsen malnutrition by decreasing appetite and increasing demand for nutrients.[vi] For a child experiencing malnutrition, bouts of diarrhea or vomiting can quickly lead to dehydration and rapidly worsen their health.[vii] Additionally, malnutrition coupled with infections or parasites can interfere with the body's ability to absorb nutrients, thus further contributing to poor growth.[viii] In these situations, child mortality is a very real threat.

Conceptual framework on the relationship between malnutrition, infections and poverty. 

In the long term:

Malnutrition remains a significant barrier to sustainable development as it creates a trap from which people cannot easily escape. Its effects are cyclical and permeate through almost all aspects of a person's life. During the first 1000 days of a child’s life, while rapid development is occurring, malnutrition can mean poor outcomes in health, cognitive development, and educational and economic attainment later in life.[ix] Malnutrition has been shown to increase the likelihood of heart disease, diabetes, kidney damage, and anemia into adulthood.[x] Another related consequence of malnutrition, coupled with a weakened immune system, is a lowered capacity to work. Decreased economic productivity, compounded by existing barriers to dignified and fair work, perpetuates poverty. Child malnutrition during the vital years of brain development can cause permanent delays in motor, cognitive, and emotional development. It may also lead to conditions such as cerebral palsy, language and communications disorders, behavioural disorders like ADHD, autism spectrum disorder, learning disabilities and dyslexia.[xi] Of course, the negative impacts of delays in brain development are coupled with external barriers to education, leading to lower scholastic achievement and higher drop-out rates.

As mentioned several times throughout this blog post, it's vital to remember that barriers to health and education already exist for many indigenous communities, outside of the challenges associated to malnutrition. We see an urbanization of services, systemic discrimination, limited funding, and corruption. These barriers are compounded by malnutrition, and vice-versa. It's all cyclical. For example, research shows us that child malnutrition rates are higher for children whose parents have low education levels.[xii] Unsurprisingly, the correlation is even stronger with maternal education levels, given mothers are generally the ones responsible for feeding their children. Again, we usually see low education levels paired with high poverty levels, creating a virtually impermeable trap of malnutrition. Furthering the link between maternal health and child health, malnourished women are more likely to have low birth-weight babies, thus perpetuating the problem across generations.[xiii]

In our projects we see parents who were themselves malnourished as children, who did not receive an education, who are working in low-paying, labour-intensive jobs, who struggle with poverty every day. The next generation thus grows up in the same circumstances, with the same limits to opportunity, with likely the same outcomes. That's why at Pop Wuj we take a holistic approach in serving these communities. We provide nutritional support for children to aid in physical and mental development. Then later on in these children's lives, we provide scholarships to further support their education. Our medical clinics offer ongoing care, from childhood into adulthood, which may otherwise be inaccessible. In this way, we strive to help families break cycles of poverty and malnutrition.

A Nutrition Program participant checks out the goings-on at the project during her checkup in La Victoria
Photo by Emily Rempel

We have 17 Global Goals that we are attempting to reach by the year 2030 and we will not get there unless we take a holistic approach to development. Without action on health and nutrition, not only won’t we achieve goals 2 (Zero Hunger) and 3 (Good Health and Well-Being) but we also won’t meet many of the other Goals, from education and gender equality to environmental sustainability and peace and justice. Please, stand in solidarity with our grassroots efforts against child malnutrition. As Mary mentioned, though our organization may not be able to singlehandedly realize Zero Hunger in Guatemala, we can help make it a reality for some.

[i] UN.org, “Sustainable Development Goals,” http://www.un.org/sustainabledevelopment/hunger/
[ii] UN.org, “Sustainable Development Goals,” http://www.un.org/sustainabledevelopment/hunger/
[iii] Nagata, J. M., Gippetti, J., Wager, S., Chavez, A., & Wise, P. H. (2016). Prevalence and Predictors of Malnutrition among Guatemalan Children at 2 Years of 
       Age. Plos ONE, 11(11), 9
[iv] Oruamabo, Raphael S. (2015). Child Malnutrition and the Millennium Development Goals: much haste but less speed?. Arch of Dis Child, 100, 19-22.
[v] Dhopeshwarker, Govind A. (1983). Effects of Malnutrition on Brain Development. Nutrition and Brain Develop. Springer, US: 49-83
[vi] Rytter, M. H., Kolte, L., Briend, A., Friis, H., & Christensen, V. B. (2014). The Immune System in Children with Malnutrition—A Systematic Review. Plos 
      ONE9(8), 1-19. doi:10.1371/journal.pone.0105017
[vii] Nagata, J. M., Gippetti, J., Wager, S., Chavez, A., & Wise, P. H. (2016). Prevalence and Predictors of Malnutrition among Guatemalan Children at 2 Years of 
       Age. Plos ONE, 11(11), 9
[viii] Nelson, C. A., Bos, K., Gunnar, M. R., & Sonuga-Barke, E. S. (2011). V. THE NEUROBIOLOGICAL TOLL OF EARLY HUMAN 
       DEPRIVATION. Monographs Of The Society For Research In Child Development76(4), 127-146. doi:10.1111/j.1540-5834.2011.00630.x
[ix] Danaei, G., Andrews, K. G., Sudfeld, C. R., Fink, G., McCoy, D. C., Peet, E., & ... Fawzi, W. W. (2016). Risk Factors for Childhood Stunting in 137 
         Developing Countries: A Comparative Risk Assessment Analysis at Global, Regional, and Country Levels. Plos Medicine, 13(10), 1-18.
[x] PBS.org, "Widespread Childhood Malnutrition is a Paradox in Agriculturally Rich Guatemala," http://www.pbs.org/newshour/bb/widespread-childhood-
[xi] Cattopadhyay, N., Saumitra, M. (2016). Developmental Outcome in Children with Malnutrition. J Nepal Paediatr Soc, 36(2), 170-177.
[xii] Nagata, J. M., Gippetti, J., Wager, S., Chavez, A., & Wise, P. H. (2016). Prevalence and Predictors of Malnutrition among Guatemalan Children at 2 Years 
        of Age. Plos ONE, 11(11), 9
[xiii] The World Bank, “World Development Indicators – Guatemala,” http://databank.worldbank.org/data/reports.aspx?source=2&country=GTM


UN News Centre, http://www.un.org/apps/news/story.asp?NewsID=51809#.WNAgdWQrLL8 
GlobalGoals.org, http://www.globalgoals.org/global-goals/no-hunger/ 
 Rytter MJH, Kolte L, Briend A, Friis H, Christensen VB (2014) The Immune System in Children with Malnutrition—A Systematic Review. PLoS ONE 9(8): 
        e105017. doi:10.1371/journal.pone.0105017