Oral district, Kompong Speu province-They had arrived by oxcart hours before, some having started early the day before. They should have been on their way home before noon.
But on this day last month, the delivery trucks of the Cambodian Red Cross had been stuck in the mud on the way to the district, leaving the waiting villagers to sit and stand patiently in the midday heat.
When the trucks finally arrived, it took several hours to unload and distribute the rations of special food, to double-check records for names and quantities and then reload the precious cargo onto the oxcarts.
It was mid-afternoon by the time villagers started home on a journey that, for some, would not end until the following day.
Once a month, this scene—vaguely reminiscent of the massive food handouts coordinated by international agencies along the Thai border in the 1980s—is repeated in Banteay Meanchey, Kompong Thom and Siem Reap provinces.
The fortified food for mothers and children that recipients carry home comes from the World Food Program, a partial response to an urgent situation.
Many Cambodians suffer from vitamin A, iron and iodine deficiencies. Compared with other challenges faced by the country this may sound negligible.
But because of these deficiencies, many 17 year-olds are so small they look as if they are only 12 years old. One out of eight schoolchildren has a deformed neck due to an enlarged thyroid gland. In at least five provinces, so many children under the age of 5 can’t see at night that the condition is now is treated as a serious public health issue. And iodine deficiencies can cause brain damage and lead to mental retardation.
Some of these conditions could be corrected if addressed early enough. For example, using iodized salt for cooking can reduce sleepiness and lethargy in the short term, according to Jenny Busch-Hallen, technical officer for nutrition at the World Health Organization.
The lack of vitamin A makes people more vulnerable to infection and disease. Without it to protect the cells lining the skin, people get lesions on their eyes, which impairs night vision and can degenerate into blindness.
Iron deficiency has created a population of anemic children and is believed to cause the death at childbirth of about 2,000 women each year.
According to the 2000 Demographic and Health Survey, six children out of 10 under the age of 5 are anemic. They are more susceptible to infectious diseases, and they have a more difficult time in school because of their limited cognitive and motor development.
More than half of the women between 15 and 49 years old are anemic, the study said.
And this is where the vicious circle begins, said Jim Tulloch, WHO representative in Cambodia. “You have malnourished mothers nourishing malnourished babies, who will become malnourished mothers.”
More than 50 percent of child deaths [in Cambodia] are associated with malnutrition one way or another, said Tulloch, who for 10 years has directed the WHO’s worldwide child health-disease program at the organization’s headquarters in Geneva.
A malnourished child gets sick and loses his appetite, which reduces his intake of nutrients and aggravates his condition, he said. As a result, one child out of eight dies before reaching 5 years in Cambodia, Tulloch said, and nearly half are too short and underweight.
Cambodia is believed to have the worst malnutrition rate in Southeast Asia.
Changing this involves drastic reforms, with the goal to reduce the poverty that is to blame for the lack of meat and fish in people’s diet. However, some low-cost measures can be taken to limit the extent of the damage.
Scientific evidence now shows that vitamin A and iron, rather than protein, can help prevent stunted growth in children, noted the NGO Helen Keller International in its report “An Overview of Nutrition Sectors Activities in Cambodia,” released in May.
Giving iron to children costs about 140 riel (about $.03) per child per school year, said Philippe Longfils, health and nutrition adviser for the Rural Development Program of Kampot and Kompong Thom provinces.
Iodized salt would go a long way to reducing iodine deficiency. But in most provinces, less than 10 percent of the households use it, said the Helen Keller report, quoting the 2000 Cambodia National Micronutrient Survey.
“People don’t understand the importance of iodized salt,” said Ping Sivlay, director of the Department of Industrial Standards at the Ministry of Industry, Mines and Energy. Since iodized salt is slightly more expensive, most people settle for regular salt, he said.
“Our goal is to have only iodized salt on the market,” he said.
To increase vitamin A intake, the government decided in 1999 to distribute the vitamin to all children up to 5 years and to women for the first eight weeks after giving birth.
This has produced mixed results, according to the Helen Keller report. The lack of resources to train health workers and to get the supplies to health centers throughout the country has led to uneven distribution.
A number of programs have been put in place to reduce vitamin A, iron and iodine deficiencies in the country. However the Helen Keller report-which reviews the nutrition projects of 58 governments, international organizations and NGOs-indicates that the scope and scale of their projects is limited and under human, material and financial constraints.
There usually is a lack of communication among organizations, according to the report. Coordinating programs should be the role of the National Council for Nutrition, said Dora Panagides, former director of Helen Keller in Cambodia and now based in Bangladesh.
But the council, which includes representatives from 13 government ministries, simply does not have the resources to do the task, she said.
And yet, results can be quick to appear. In some villages in Kompong Speu province where fortified food has been distributed for nearly two years, women and children have obviously gained weight, said Hem Chantou, WFP national program officer and head of the organization’s regional office in Kompong Speu.
“They are not so pale anymore,” he said.
In September 2000, WFP started distributing fortified food in the four provinces as an 18-month pilot project, said Hege Elsebutangen Nome, program officer for the WFP. This led to a 21-month program that was launched this September, she said.
Every month, 50,000 children under 5 years, 6,500 pregnant women and 6,500 nursing mothers receive a corn-soya blend fortified with vitamins and minerals, vegetable oil fortified with vitamin A, a bit of sugar for taste and some rice.
“I usually turn [the corn-soya blend] into cakes for the children at breakfast,” said Seak Bouch, a mother and food recipient from Chamnup village in Oral district.
Records are kept on each recipient, and the children’s weight regularly checked, said Nou Ty, senior field monitor for WFP. The number of severely underweight children has declined since the start of the pilot project, he said.
But WFP’s budget for the program is only $5 million, said Rebecca Hansen, WFP director in Cambodia. The organization would have liked to extend it to the whole country, but does not have the resources to do so, she said.
Still, women in the program receive the fortified food from their third month of pregnancy and during their first six months of nursing, while babies must be exclusively breastfed.
The most crucial time for a child’s development is from the womb up to 2 years old, said Nyunt Nyunt Yi, project officer for health and nutrition at the UN Children’s Fund.
“If you don’t put the emphasis on the first two years, you don’t get proper brain development,” she said.
This makes it important for mothers to be healthy, especially while they nurse, Nyunt Nyunt Yi said. “Otherwise malnutrition will be carried into the next generation.”
In addition to distributing the fortified food, village volunteers also educate people on proper nutrition.
“I have taught mothers in my village to feed their babies babar [boiled rice soup] mixed with vegetables,” said Lim Sam, a volunteer from Yang Pis village in Oral district.
One obstacle to good nutrition is the cultural beliefs about children’s food that Cambodians have inherited, Longfils said.
A research study conducted in Kampot province in 1999 showed that Cambodian food taboos extended to “everything children under 5 must eat,” in order to be healthy, he said. This makes it imperative to educate mothers on the need to add meat or fish, fruit and vegetables to babar, said Longfils.
And international funding for nutrition is also difficult to obtain, Tulloch said.
“I think that we’re in a period during which the international community tends to concentrate on issues with obvious fixes rather than issues with complicated remedies,” he said.
International donors are looking for programs whose results can be reported in concrete terms to their countries’ taxpayers-facts and figures that can be measured and compared over limited periods of time, he said.
“Therefore, in general, child health and nutrition is not getting the attention it deserves,” he said.