AS SMALL children bathed nearby in a discoloured puddle while others shared the last remains of instant ramen noodles raw from the bag, Ros Soken settled under one of Sras Por village’s stilted houses earlier this week and spoke of her son.
Lacking access to nutritional food, the 29-year-old widow feeds her four-year-old a diet consisting mainly of rice and soy sauce. The boy’s smaller than average body suffers a heart condition and he is sometimes too weak to walk, Soken said.
She glanced at the ground and spoke in an airy monotone when pondering her family’s future. A breast cancer patient who can’t afford treatment without selling her property – something that would leave her and her son homeless – Soken simply hopes she lives long enough to care for her malnourished son until he can care for himself.
Albeit harrowing, Soken’s struggle is not unique in her community, where about 120 children across 140 families are “stunted” like her son – smaller than normal due to nutritional deficiencies – according to a community leader.
The problem remains rampant across the country, with just under 40 per cent of children younger than five afflicted with the condition, according to a 2010 World Health Organization study. And despite huge sums of aid flowing into the Kingdom it’s barely improved in the past five years.
“They don’t seem sick,” said Giorgia Paiella, a nutrition specialist with WHO in Cambodia. “But in the end, if you are to look at their physical growth or their cognitive development, both are really compromised.”
The condition of stunting is the result of a variety of deficiencies, Paiella said. Without enough protein and vitamins A, B1 and C, physical growth and cognitive development slows.
Children born to poor mothers often get fewer nutrients than necessary upon conception, Paiella said. With folic acid and iron deficiencies causing anaemia in a majority of Cambodian women of reproductive age, their children are deprived of key nutrients before birth.
“If [the mother] and baby at that time receive the right amount of micronutrients . . . they can recover,” Paiella said. “But that is normally not the case.”
Paiella calls the first 1,000 days from a child’s conception “the window of opportunity”, because after this time period, damage caused from malnutrition is irreversible.
The effects of chronic childhood malnourishment outlast childhood, data show. Chronically malnourished children have higher rates of cardiac disease and diabetes, achieve less success in school and are more likely to drop out, according to a 2011 Early Childhood Nutritional Factsheet by Cambodia’s Council for Agricultural and Rural Development, or CARD. The Kingdom loses more than $146 million in GDP to vitamin and mineral deficiencies each year, the factsheet says.
The Cambodian government began dealing with chronic malnutrition systematically in 1999, the year after it established CARD to cover all nutrition issues, said Srun Darith, the body’s deputy secretary.
“The level of malnutrition is still high,” Darith told the Post. “There is a lot of improvement, but malnutrition is still high.”
A joint study by the World Health Organisation, Unicef and the Demographic and Health Survey ranked Cambodia’s prevalence of stunting in children younger than five as the world’s third-highest – behind only Ethiopia and North Korea, respectively – between 1990 and 1998. That report, which included data from 96 countries, put Cambodia’s stunting rate at 56 per cent.
Stunting levels in the Kingdom dipped to just below 50 per cent in 2000 and lessened another 10 per cent in the decade after that, according to WHO data. Improvement between 2000 and 2010 largely came in the decade’s first five years and has remained essentially stagnant since then.
The global financial crisis slowed the stream of foreign and domestic funding, said Darith, who acknowledged the slowing of progress. In addition, reducing stunting is an issue with no clear solution, he added.
“It’s not like you’re building a road or bridge or dam,” Darith said. “The outcome of the nutrition program tends to be a little abstract.”
Despite the slowed progress, Darith has faith that Cambodia will meet their Millennium Development Goal, which calls for a two-thirds reduction in stunting between 1990 and 2015. Through the Ministry of Health, CARD plans to establish a coordinated nutrition policy for the Kingdom within the next few months, he said. Darith did not elaborate on what the policy may entail.
The government provides some support to programs that provide food and nutritional education, said Dr Mam Sotheara, medical coordinator for human rights group Licadho.
After seeing the consequences of malnutrition in children first-hand, Sotheara said the government should focus more resources toward providing nutritious food as well as education on nutrition, especially to people in far-flung villages that lack access to fruits, vegetables and proteins.
“In remote areas, there are a lot of [chronically] malnourished children,” Sotheara said. “They lack quantity and quality in calories and proteins.”
Paiella echoed the need for education for villagers in the provinces. In her opinion, great strides against stunting could be made by encouraging mothers to exclusively feed their children breast milk for at least the first six months of their lives.
Another viable solution, Paiella said, would be to distribute vitamin powder to people in remote areas. The powders could fortify staple foods like rice and noodles with nutrients to which people in these areas have little access.
But access to proper food is just one aspect of the complex issue of chronic malnutrition in Cambodia, said Karin Shelzig, senior social specialist at the Asia Development bank. Changing certain habits that contribute to nutritional deficiencies can pose more difficulty than funding food programs.
“If you look across income quintiles . . . all income quintiles are affected by childhood malnutrition,” Shelzig said. “Changing behaviour is tricky, and you can’t really put a dollar value on that.”
Overlooking simple hygienic tasks like washing hands with soap before feeding children can have disastrous effects on their nutritional well-being, Shelzig said, including diarrhoea. Young children with frequent diarrhoea develop irreparable damage, making them unable to properly absorb nutrients.
The importance of hygiene
In a country where 80 per cent of the population lives in rural areas and four out of five people lack access to toilets, Shelzig places improper hygiene as a leading cause of chronic malnutrition in Cambodia.
An ADB analysis this year concludes that government-led programs focusing on food security, nutrition and sanitation could reduce chronic malnutrition. Partnerships between the government and NGOs, possibly sponsored by a mutual social protection fund, could address the issue.
But while the government currently provides a platform for NGOs and encourages their work, they do very little to directly help, said Blaed Perkins, co-founder of Feeding Dreams Cambodia.
“The Cambodian government really hasn’t done that much when it comes to the problem of solving malnutrition,” Perkins said.
Increased funding from the government would not likely alleviate the problem either, Perkins said, since funds often pass through several channels, each of which takes a cut. By the time money reaches the people for which it was intended, it amounts to a fraction of what was expended.
“If corruption could go down, the government might be able to make a change,” Perkins said. “If the government wants to be able to reach out to poor people they really need to go directly to the poor people.”
CARD deputy director Darith denied the corruption, saying the government, in fact, works hand in glove with NGOs on the issue.
“Almost all the programs are implemented among the ministry and the NGOs,” Darith said. “[If the government is corrupt] then the NGOs make corruption too, because they are working together.”
In any case, people in the relocation community of Sras Por find themselves in a sort of funding quagmire when it comes to medical and nutritional aid, said Toch Khon, a 47-year-old community leader.
The roughly 500 people who live there were moved to the village, which lacks electricity and on-site clean water, from Borei Keila village in Phnom Penh to make way for a Phan Imex company development in January of 2012.
Since the move, the Cambodian Red Cross and the government have deferred responsibility for providing health and nutritional aid for people in Sras Por to Phan Imex, Khon said. But the company has provided no assistance.
Like many others around her, Ros Soken is painfully conscious of the direct impact the absence of support has on her life.
Without the ability to travel from her home to a job in Phnom Penh, the money to pay for cancer treatments or assistance to feed her small, undernourished four-year-old, deterioration seems the only family activity in which she can participate with her son.