Celestina of Porcón Alto, a rural region high in the Andes, whose family has lived on the same plot of land for generations. Credit: Andrea Vale/IPS

By Andrea Vale
PORCÓN, Peru, Oct 6 2017 (IPS)

Good healthcare can be hard to get – particularly when one lives on top of a mountain. The road to Porcón in the Cajamarca region of Peru, therefore, is as breathtaking as it is sobering. With every step further into its isolated natural beauty, a group of volunteers sent to deliver healthcare essentials are reminded how long the trek would be in an emergency.

After a bus has taken the volunteers as far as it can, to the rim of a sweeping valley dipping into the basin of a ring of mountains, they start their hike.“We have a lot of fear,” Celestina says. “The doctors are always telling us that they’re going to help us and heal us, but we can’t always get to them and they’re not able to get to us."

It’s not very long mile-wise, but they stumble over unforgiving drops in a rocky wind that leads them through tilted pastures resting on the sides of the mountains. The looming brown stillness is disrupted by their panting, at a loss of breath from the gasping altitude.

At the end lies a community of artisans who live in close proximity to one another in Porcón Alto, a rural region high in the Andes.

They’ve been waiting. Once the volunteers arrive, several women filter out into the pasture where they’ve set up shop and sit cross-legged around them, all accompanied by toddlers clutching at their long skirts and babies peeking out of the tops of the shawls slung over their backs to carry infants, or vegetables.

They have a flood of questions ready, about basic nutrition, exercise, disease prevention. They have a waiting list of ailments to look at – my child has this rash. My child can’t say his R’s. It hurts when I stand up from bed.

Immediately put to work, volunteers begin taking their blood pressure, weighing them, measuring their heart rates and their blood glucose levels. Under the shadow cast by one woman’s tall brimmed hat her skin is wrinkled in layers, leathery and toughened from years of work in the sun. She looks anywhere between 40 and 60, balancing a squirming toddler in her lap while she squints at the volunteer helping her with rapt attention and concern. But a glance at her chart reveals that she is only 22.

One woman sits in the center of the others, shucking corn with a baby tied to her back. Her eyes crinkle with smile lines and her elements-exposed skin is a mosaic of black freckles and brown creases. Her name is Celestina.

Porcón is home to her in a deep sense – her family has lived on this exact plot of land for generations.

“The house over there was taken down, but that’s where my grandmother and her mother lived,” she says in Spanish, gesturing out towards a rolling plot of land.

As to what life has been like, living high up here: “Sometimes it’s good, sometimes it’s bad. Sometimes I get worried. My daughter is sick right now, so I’m sad right now,” Celestina says, touching her daughter’s face as the baby girl plays in her lap. Baby Analee, she says, was bit by an insect just this morning. Analee’s cheek is already massively swollen with a red welt.

Fearing for her daughter is a constant reality of existence for Celestina.

“When I’m sleeping I can forget, but otherwise there’s always that worry for my child,” she says. “She needs to go to school, she needs to work, and I’m always worried about her, to know that she’ll be okay.”

Despite how long her family has lived on this land, Celestina says without a hint of hesitation that she wishes Analee could grow up in an urban area, perhaps the city Cajamarca below.

“Of course I want to live out in the city, but we don’t have land. Where would we build a house? Here, being out in the country, we just cook, we clean, we try to bathe, and we wait. All we can do is wait for the proper transportation to get to Cajamarca to try to get the proper attention if someone is sick.”

She says that there are no home remedies that she or anyone in the community uses to try to treat illness. Their best defense is simply the best level of hygiene they can achieve, and oftentimes it isn’t enough.

According to the Pan American Health Organization, only 19.1% of the urban population in Peru make up the country’s total poverty – as compared to 54.2% of rural peoples. In regards to extreme poverty, the contrast is even starker – 2.5% of the urban population, and 23.3% of the rural.

Celestina is 38 years old. She has the health of a 60-year-old. Plagued with health struggles since childhood, she currently suffers from chronic eyesight and stomach trouble.

But she brushes this acknowledgement off and automatically returns her attention to her baby.

“My daughter is sick and I am worried,” she says. “Always, I am scared for her.”

Celestina may worry about emergency illness striking, but what her and the other community members don’t realize is that the real threat of living in such isolation is not one-time tragedies, but rather chronic health problems. Of the children screened in Porcón, one-fourth were underweight and one-fourth were either at risk of being overweight or actually overweight. Of the adults screened, 33% were obese and 42% were overweight.

Most of the people examined during the health screenings, both in Porcón and across Cajamarca, had hypertension and were overweight. An inordinate number had diabetes and were completely unaware of it, ignorant to what caused the disease. One woman’s blood glucose level was close to 230 – the volunteer who tested her was so shocked that she tested the level twice more, sure that that initial reading couldn’t be possible.

Uneducated on signs of cancer and prevention techniques, many have had parents and grandparents pass away from the disease and simply chalked it up to having ‘just died,’ without a known cause.

According to the World Health Organization, the current national Human Resources for Health Density in Peru – meaning doctors, nurses and midwives – is 17.8 per 10,000 population. That distribution, however, is extremely inequitable, with rural areas usually having an HRH density of below ten. Lima, for instance, has three times more physicians per population – 15.4 – than Huancavelica, one of the poorest cities in Peru and populated in majority by indigenous peoples. 89.1% of births in urban regions are assisted by a professional – while only 42.9% of births in rural areas are.

Consequently, it’s perhaps not surprising that child mortality rates in Peruvian rural areas are almost twice that of urban areas – 40% to 26%.  According to the Pan American Health Organization, 35.3% of adults in rural areas of Peru are overweight, and 16.5% are obese. Only 40% of them perform any “moderate physical activity” – all of the health screenings concluded with group exercise classes.

Without doctors nearby, without easy and reliable transportation to get to the closest doctors, and without health education, Celestina has to live in constant fear. There is fear for her neighbors and for herself – but above all, fear for her baby. There is fear that disease will strike, that accidents will happen, that unexplained illness will come. Because when it does, Celestina and the rest of the community are left alone on top of the Andes with only their best abilities as a defense – uneducated, unequipped and without adequate and reliable transportation.

“We have a lot of fear,” Celestina says, “The doctors are always telling us that they’re going to help us and heal us, but we can’t always get to them and they’re not able to get to us. They’re always promising that they’re going to help us, but it never happens because they’re so far.”

For now, all that Celestina and the rest of Porcón can do is wait.

“The only thing we can do is wait until we can go to the doctor,” she says, “To go to the doctor and then wait again. Sometimes there’s nobody.”

Prof Grace Irimu shows IPS a drip feed bag and a copy of Kenya’s ‘Basic Paediatric Protocols’ as she explains the importance of intravenous treatment in saving the lives of young children affected by acute watery diarrhoea. Credit: Miriam Gathigah/IPS

By Miriam Gathigah
NAIROBI, May 23 2015 (IPS)

Acute watery diarrhoea is a major killer of young children but misunderstanding over the benefits of fluid treatment is preventing many Kenyan parents from resorting to this life-saving technique and threatening to reverse the strides that the country has made in child health.

The 2014 Kenya Demographic and Health Survey, released in April this year, reports that the country’s under-five mortality rate fell to 52 deaths per 1,000 live births in 2014, down from the 74 deaths in 2008-09, but still far from the 32 per 1,000 live births targeted under the Millennium Development Goals (MDGs).“Parents must … understand that rapid fluid treatment is life-saving for children diagnosed with shock or poor blood circulation due to diarrhoea” – Prof Grace Irimu, Associate Professor of Paediatrics, University of Nairobi

The primary treatment for acute watery diarrhoea is rehydration, administered intravenously in the most severe cases of very young children suffering from shock after losing excessively high quantities of body fluids. A fluid bolus – or rapid liquid dose – delivered directly through an intravenous drip allows a much faster delivery than oral rehydration.

However, notes nurse Esther Mayaka at the Jamii Clinic in Mathare, Nairobi, “parents of children brought to hospital with acute watery diarrhoea are refusing to have them put on [drip] fluid treatment and this is a major concern because diarrhoea is a leading killer among children and giving fluids is still the main solution.”

She told IPS that the ongoing rains and floods in many parts of the country “have created a comeback for diseases like cholera whose most telling sign is watery diarrhoea which needs to be managed with fluids.”

In February this year, Kenya’s Director of Medical Services, Dr Nicholas Muraguri, issued a cholera outbreak alert following an increase in cases of acute watery diarrhoea in several counties, including Homa Bay, Migori and Nairobi.

According to Prof Grace Irimu, Associate Professor of Paediatrics at the University of Nairobi, the reluctance to resort to drip fluid treatment has arisen due to misunderstanding generated by a Fluid Expansion As Supportive Therapy (FEAST) study in 2011 to establish whether the bolus technique was the best practice to use among children diagnosed with shock.

The FEAST study, which was conducted among children in Kenya, Tanzania and Uganda, found that fluid boluses increased 48-hour mortality in critically-ill children with poor blood circulation or shock in these resource-limited settings in Africa, but Irimu told IPS that the study excluded diarrhoea and only studied illnesses associated with fever, such malaria and sepsis.

“Parents must therefore understand that rapid fluid treatment is life-saving for children diagnosed with shock or poor blood circulation due to diarrhoea,” she said.

The Kenya Paediatric Association is also trying to set the record straight and, in a statement shared with IPS, the association reiterated that “diarrhoea complicated by severe dehydration is one of the biggest killers of children globally.”

According to the paediatrics association, the FEAST study excluded children with diarrhoea and dehydration because “the value of giving fluids in this group is well known. Giving appropriate fluid therapy is essential.”

Prof Irimu told IPS that the FEAST study had led to a revision of the ‘Basic Paediatric Protocols’, Kenya’s national guidelines for paediatric care, and clauses that address the treatment of diarrhoea were also revised.

Previously, a child diagnosed with shock as a result of diarrhoea would be given fluids in three cycles, every 15 minutes depending on the response. Now, the child receives the fluids in two cycles and if there is no response, health providers are advised to proceed to slower fluid administration where the child is given the amount that the body needs, depending on the level of dehydration.

Meanwhile, the country continues to make strides in dealing with HIV/AIDS – another critical health issue covered by the MDGs – among children. Studies show that the number of children with HIV aged between 18 months and 14 years fell from 184,000 in 2007 to 104,000 in 2012, according to the most recent Kenya Aids Indicator Survey.

However, Prof Joseph Karanja, a reproductive health and HIV/AIDs expert in Nairobi, says that the country can still do better because “through available antiretroviral drugs as a preventive measure among HIV positive mothers, HIV transmission to the infant can be reduced to as low as one percent.”

Dr Pauline Samia, a paediatric neurologist and a board member of the Kenya Paediatric Association, says that there is also a commitment to address conditions that challenge the management of HIV among children such as epilepsy.

“Though research in this area is limited, an estimated 6.7 percent of children with HIV also have epilepsy, with at least 50 percent of children with HIV having central nervous system problems such as delayed development, behavioural challenges and convulsions,” she observes.

Regarding progress in other MDGs, some progress has been made in reducing the prevalence of underweight children less than five years of age, one of the goals set for eradicating extreme hunger and poverty.

The 2014 Kenya Demographic and Health Survey reports that not only has childhood malnutrition declined significantly, from 35 percent in 2008 to the current 26 percent, but the prevalence of underweight children also decreased from 16 percent in 2008 to 11 percent in 2014.

On the front of improving maternal health, the survey says that while maternal mortality remains high at 488 deaths in every 100,000 live births, in the past five years more than three in five births (61 percent) took place in healthcare facilities, a marked improvement compared with the 43 percent in 2008.

Edited by Phil Harris   

Nepal has one of the highest rates of malnutrition in the world. Over 41 percent of the country’s children suffer from chronic malnutrition, predominantly in rural areas. Credit: Naresh Newar/IPS

By Jomo Kwame Sundaram
ROME, Mar 9 2015 (IPS)

In 2014, an estimated 805 million people – one in nine people worldwide – were estimated to be chronically hungry. All but 14 million of the world’s hungry live in developing countries, i.e., 791 million are in developing countries, where the share of the hungry has declined by less than half – from 23.4 per cent (1990-1992) to 13.5 per cent (2012-2014).

Progress uneven

Overall progress has been highly uneven. Some countries and regions have seen only slow progress in reducing hunger, while the absolute number of hungry has even increased in several cases. Marked differences in reducing undernourishment have persisted across regions.Nutrition failures are due not only to insufficient food access, but also to poor health conditions and the high incidence of diseases such as diarrhoea, malaria, HIV/AIDS and tuberculosis.

There have been significant reductions in both the estimated share and number of undernourished in most countries in South-East Asia, East Asia, Central Asia, Latin America and the Caribbean – where the target of halving the proportion of the hungry has been reached, or nearly reached.

Progress in sub-Saharan Africa has been more limited, and the region now has the highest prevalence of undernourishment. West Asia has seen a rise in the share of the hungry compared to 1990-1992, while progress in South Asia and Oceania has not been sufficient to meet the MDG hunger target by 2015.

In several countries, underweight (low weight-for-age) and stunting (inadequate length or height for age) persist among children, even when undernourishment is low and most people have access to sufficient food. Nutrition failures are due not only to insufficient food access, but also to poor health conditions and the high incidence of diseases such as diarrhoea, malaria, HIV/AIDS and tuberculosis.

One in seven children under five are underweight

An estimated 99 million children under five years of age were underweight in 2012. This represents a fall of 38 per cent from an estimated 160 million underweight children in 1990. Yet, 15 per cent, or about one in seven, of all children under five worldwide are underweight.

East Asia has led all regions with the largest decrease of underweight children between 1990 and 2012, followed by the Caucasus and Central Asia, Latin America and the Caribbean, and West Asia. While the proportion of underweight children was highest in South Asia, the region has also experienced the largest absolute decrease since 1990, contributing significantly to the global decrease over the period.

Despite a modest reduction in the proportion of underweight children, Sub-Saharan Africa was the only region where the number of undernourished children increased, rising from 27 million in 1990 to 32 million in 2012.

In 2013, about 17 per cent, or 98 million children under five years of age in developing countries were underweight. Underweight is most widespread in South Asia (30 per cent), followed by West Africa (21 per cent), Oceania and East Africa (both 19 per cent) and South-East Asia and Central Africa (both 16 per cent) and Southern Africa (12 per cent).

Underweight prevalence was below 10 per cent in 2013 in East, Central and West Asia, North Africa and Latin America and the Caribbean.

Globally, the proportion of underweight children under five years of age declined from 25 per cent to 15 per cent between 1990 and 2013. Africa experienced the smallest decrease, with underweight prevalence declining from 23 per cent in 1990 to 17 per cent in 2013, while in Asia, it fell from 32 per cent to 18 per cent, and in Latin America and the Caribbean, from 8 per cent to 3 per cent.

This means Asia and Latin America and the Caribbean are likely to meet the MDG target for underweight, while Africa is likely to fall short, achieving only about half of the reduction target. And although Asia as a whole is likely to meet the MDG target, underweight rates remain very high in South Asia (30 per cent). With its large, growing population, South Asia will be home to 53 million underweight children in 2013.

One in four children under five are stunted

Stunting is a better indicator than underweight for capturing the cumulative effects of child undernutrition and infection during the critical thousand day period from conception through the first two years of a child’s life. Stunting is also more common than underweight, with one in four children globally affected in 2012.

Stunting is caused by long-term inadequate dietary intake and continuing bouts of infection and disease, often beginning with maternal malnutrition, which leads to poor fetal growth, low birth weight and poor growth. Stunting causes permanent impairment to cognitive and physical development that can lower educational attainment and reduce adult incomes.

Although the prevalence of stunting in children under five fell from about 40 per cent in 1990 to 25 per cent in 2012, an estimated 161 million children under five in 2014 remained at risk of diminished cognitive and physical development due to chronic undernutrition.

Nearly all regions in the world have seen declines in the number of children affected by stunting. The exception is sub-Saharan Africa, where the number of stunted children increased by a third, from 44 million to 58 million between 1990 and 2012.

Lessons

In countries where low undernourishment coexists with high malnutrition, specially-designed nutrition-enhancing interventions may be crucial to address early childhood stunting. Improvements in nutrition generally require complementary policies, including improving health conditions, hygiene, water, sanitation and education. More sophisticated and creative approaches to coordination as well as adequate resources are needed.

The Second International Conference of Nutrition in Rome in November 2014 articulated coherent bases for accelerated progress to overcome all types of malnutrition (undernourishment, micronutrient deficiencies, obesity) and defined pathways to international cooperation and support for integrated national nutrition efforts.

The international community, including those in the U.N. system, must come together to improve coordination for a sustained effort against malnutrition over the next decade.

But with high levels of deprivation, unemployment and underemployment continuing and likely to prevail in the world for the foreseeable future, poverty and hunger are unlikely to be overcome without the extension of universal social protection to all in need.

Edited by Kitty Stapp

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