Laos has made impressive strides in economic growth, but its record on childhood nutrition may dash the country's hopes of graduating from least-developed country status by 2020.
Economic growth averaging 7% annually for the last five years has enabled Laos to make some staggering achievements. From 1995 to 2014, the poverty rate fell from 46% to 24%. Enrolment in primary education climbed from 58% to 84%, and infant mortality dropped from 170 to 98 deaths per thousand live births.
However, chronic malnutrition persists in the country. Currently, 6.4% of children below five years of age suffer from wasting, or low weight-to-height ratio. Stunting, or low height to weight, is documented in 43.8% of children. While wasting is an indication of acute hunger or malnourishment, stunting results from poor socioeconomic conditions and/or illness, or inappropriate feeding at an early age.
The window is relatively small for a child to avoid stunting and to develop a good immune system as well as motor skills, nutritionists say. The first 1,000 days of a child's life are critical — missing this window has unfortunate consequences. Malnutrition compromises the immune system, leading to poor health and perpetuating the cycle of poverty.
Typically nutrition aid programmes direct efforts toward prenatal care and post-partum feeding practices. In many ethnic communities, there are social behaviours that undermine long-term health. For example, some cultural practices permit women to eat only rice and salt for up to three months after giving birth. Certain communities feed babies sticky rice at birth, thereby forgoing the nutrient and immune system advantages of exclusive breastfeeding.
An estimated 70% of the population of Laos lives in rural areas where poverty is 50% higher than the national average. Rural communities practise subsistence agriculture, and productivity is moderate to low. Slash-and-burn agriculture is widely practised in upland areas, and here the incidence of both poverty and malnutrition is highest.
According to a 2014 UN Country Status report, socioeconomic statistics in Laos vary significantly based on geographical factors such as elevation and distance from the road. In other words, socio-economic indicators for health, nutrition and education decline the farther up you move in elevation and the farther you get from road access. According to some, these inequities are not properly acknowledged or addressed.
Since the late 1980s, the Lao government has actively relocated ethnic groups living in high elevations to lowland areas, where they can be linked to education, healthcare and roads. However, upland farmers often do not have access to land or the know-how to farm in lowland areas. Ultimately, these communities live alongside the road, but still practise slash-and-burn agriculture and engage primarily in rice-based monoculture.
While past programmes to curb malnutrition have made a dent, rates of malnutrition in Laos remain at disturbing levels. The 2010 UN National Human Development Report claims that poverty and nutrition are concentrated in seven provinces, and this has not changed much in the past 20 years.
"As in many developing countries, it is a matter of resources," said Stefania Dina, country programme manager for the International Fund for Agricultural Development (IFAD). "In Laos, it is also a matter of approach. Challenges here include limited capacity, a scattered population comprising many ethnic groups, food taboos, and an ingrained practice of working by sector instead of multi-sectorally."
Both the government and international aid agencies realise the need for new approaches. In 2011, the government drafted a Nutrition Strategy and Action Plan and formed a National Nutrition Committee to help development and donor agencies work effectively with the ministries that oversee health, education, agriculture and land policies.
As well, the government in 2011 joined Scaling Up Nutrition (SUN), a global consortium of government leaders, UN staff, civil society, businesses and researchers dedicated to reducing malnutrition. In this collaboration, the Vientiane government is working with the UN to develop a strategic process to address nutrition through multi-sector channels.
"The World Bank and the UN country team recently participated in a review of the country's Millennium Development Goals (MDG) on its nutrition target, the most off-track MDG target for the country," said Kaarina Immonen, the UN country programme director in Laos.
"The government of Laos is committed to seeing a full range of high-priority interventions, from health, agriculture, education, and water sanitation and hygiene sectors implemented in all target areas simultaneously to tackle malnutrition."
According to Ms Dina, the real challenge for the government and aid workers is to break away from the previous practice of piecemeal intervention, be it in agriculture, health or education, where sectors do not coordinate their actions.
"We have to deliver a package of high-impact interventions, ranging from diversified homestead production, nutrition education, water and sanitation, health service and income-generation activities to the same children and women in the same village at the same time," she said.
"A child who does not eat a nutritious balanced diet, has no access to water and sanitation and basic health services is condemned to become malnourished."
With UN support, the government has developed a National Multisectoral Food and Nutrition Security Action Plan (MFNSAP), covering the period from 2014-20. Pilot projects run by the IFAD and other development partners began last year in Oudomxay province.
"The pilots are showing already some promising results, as well as one important lesson: a bottom-up approach empowering village nutrition committees is fundamental, as well as full political support from government authorities," said Ms Dina.
However, some Laos-based development agencies contend that no current strategy adequately addresses the role of land tenure in fighting malnutrition and providing food security. Since 2000, Laos has awarded 2,642 land concessions for natural resource, hydropower and large-scale agricultural projects, according to a report by the Centre for Development and Environment (CDE). While these concessions have fuelled foreign direct investment and account for a significant portion of national revenue, the benefits have not transformed into investment in public infrastructure and services, such as health and education.
International aid agencies critical of the Communist government's land policies declined to be named for this story for fear of causing setbacks to their fieldwork.
Dominik Wellman, in a 2012 paper prepared for the German development agency Gesellschaft für Internationale Zusammenarbeit (GIZ) and the Lao government, wrote: "The concession inventory suggests that currently about 5 million hectares of Land in Laos are leased or conceded to either domestic or foreign parties."
In other words 21% of the total territory in Laos is leased, and roughly 13% of Lao villages have at least one concession within their boundaries. "The average poverty rate of these affected villages is slightly above the national average. Taking into account that almost 80% of Laos consists of mountainous regions, it quickly draws another picture and the future availability of favourable arable land may become an issue," Mr Wellman wrote.
To this end, the CDE is conducting an inventory to see precisely how land concessions are affecting nutrition, health and poverty rates in rural Laos. "Using our existing data on land concessions and leases, we are currently exploring the possibility of conducting a new inventory where we look at the quality of investment in all aspects of land deal," said CDE senior scientist Cornelia Hett.
Questionnaires were distributed to gauge the impact of concession projects on villages. "One prominent answer is access to forest collection for non-timber forest products," said Ms Hutt, suggesting that land, whether in the form of arable fields or forests, is a vital source for food and income.
The existence of a concession from which local residents are barred could potentially compromise food security, exacerbate malnutrition and perpetuate cycles of poverty.
Miles Kenney-Lazar, who is collaborating with the Lao Land Issues Working Group (LLWG), has been conducting research on land concession governance, with a focus on to land tenure and food security issues. "Few studies document the relationships between land tenure and food security, whether using census data or case studies," he said. "Therefore, it is challenging to make a strong, evidence-based claim about the connections between land tenure security and food security, even though the links may seem obvious."
Mr Kenney-Lazar's research suggests potential ways in which land tenure and food insecurity are linked. In recent years, the government has courted foreign investment to provide funds for public services expenditures. But rapid GDP growth has not led to a significant decline in malnutrition and food insecurity.
A possible reason is that foreign investments in the natural resource sector commonly dispossess the rural poor of agricultural and forest lands, which are critically important for agrarian livelihoods and access to food, he said.