Spiderman is coiled for action across three-year-old Samuel’s bloated tummy. But the boy under the superhero T-shirt is floppy with lethargy. He mutely eyes the doctor from his aunt Margaret’s lap and clutches a half-eaten frankfurter in one grubby hand.

It’s not exactly health food, but paediatrician Dr Henry Welch is nonetheless pleased.

“What will he have for dinner?” he asks Margaret, who has brought Samuel for his checkup at the nutrition clinic at Port Moresby general hospital in Papua New Guinea. Rice, chicken, onion, carrots, some cabbage soup, she lists. Welch, an American specialist who has been working in PNG for several years, approves – too many of the kids he sees are being raised on daily servings of Maggi noodles.

Samuel, three, was admitted to hospital with severe malnutrition. Photograph: Jo Chandler

“How about eggs? If you could add an egg I would be happier – more protein.”

Samuel was admitted to the children’s ward a few weeks earlier with severe malnutrition and tuberculosis. Now back home, he’s taking daily Plumpy’nut, the high-energy paste that has become the life-saving staple for malnourished children around the world. But his limbs are still too skinny; his head too heavy for his undersized body.

Even if Samuel manages to regain a healthy weight, he will suffer the consequences of malnutrition all his life. Stunting, of body and of mind, is forever.

This crippling legacy is borne by almost one in two children in the Pacific nation, which has the fourth-highest child stunting rate in the world, according to the 2016 Global Nutrition Report.

PNG health data implicates malnutrition in about one-third of hospital deaths of children under five. But a 2017 analysis for Save the Children Australia painted an even more dire picture, identifying malnutrition as the likely cause of up to 76% of total deaths of children under five across the country’s health facilities.

The report says it is an urgent threat to more than half a million of the nation’s children, and to its economic prospects. The analysis, by Frontier Economics, estimates the cost of child undernutrition could be as high as 8.45% of the nation’s GDP, and there are indicators that the number of children being damaged may have risen despite recent economic growth and increased overseas aid.

Malnutrition has always been here, but it’s growing in proportion with the population, unemployment, the cost of living Kone Sobi, director of paediatric services, Port Moresby

Given the lush tropical conditions of the landscape, fertile soil, resourceful farmers and Pacific ocean bounty, PNG’s malnutrition crisis confounds and distresses even the experts. “I’ve asked these questions many, many times,” says Dr Kone Sobi, director of paediatric services at Port Moresby. “We’ve got the resources, we’ve got the land … We should be exporting [food].”

But malnutrition is not usually about food scarcity, explains Hanifa Namusoke of Unicef. “We are talking about quality – quantity is not a problem here. Mothers and children eat and get satisfied, but the quality – protein, nutrients – won’t promote growth.”

For a child to be stunted, they are either not getting the nutrients they need, or they are leached from them by illnesses like diarrhoea. Both issues are at play in PNG. Vaccination rates for preventable diseases are low – an issue behind a recent outbreak of polio 18 years after the country was declared polio-free.

“Children fall sick and when a body is sick it uses a lot of nutrients to try to combat infection,” says Namusoke, originally from Uganda. She came to PNG in 2014 to help overhaul its hospital protocols for dealing with undernourished children.

“Many children with malnutrition were dying,” she recalls. Her task was to provide expertise to health workers on how to better assess, diagnose and treat severe malnutrition. “And yes, we have steadily reduced the case fatality rate in several hospitals.”

Now the focus is on trying to prevent children ending up in hospital in the first place. That means ensuring adequate nutrition in the critical first 1,000 days of life.

Papua New Guinea has the fourth-highest child stunting rate in the world. Photograph: Majella Hurley/Save The Children

A woman living on subsistence agriculture – as 80% of the country’s estimated 8.5 million people do – may not have access to a diet that includes nutrients for a healthy pregnancy. She may not have access to the education and water to prepare meals for her family in hygienic conditions. There is also a risk that her child’s nutritional reserves could be drained by malaria, intestinal worms, or repeated bouts of diarrhoea that inflame the gut and inhibit capacity to absorb nutrients.

Majella Hurney of Save the Children Australia, says there is an alarming lack of understanding of how to feed babies.

“Mothers in East Sepik [Province] said they introduced complementary food, such as sago and fish soup, as early as two days after birth because they believed it would make their baby strong,” she says.

During her field research, Hurney also saw a young mother feeding her newborn sago mixed with water from a swamp containing human and animal faeces. In Port Moresby, she met a mother who fed her three-month-old chocolate milk thinking it to be better than breastmilk.



“This highlights the urgent need to train and support health workers,” she says.

Geography is also a powerful determinant of nutrition. On coasts and rivers people have fish and sago, but vegetables are limited. In the mountainous rural areas, diets rely on tubers like sweet potato. These have less zinc than animal protein and can impact foetal development. Pigs are prized and slaughtered for ceremonial occasions, but there may be long periods without any meat, and when it does come it won’t be prepared in forms that can be fed to small children.

Fast-growing urban populations rely on cheap processed foods with low nutritional value – tinned meat and fish, rice, instant noodles.

“Port Moresby is surrounded by urban squatter settlements … with no proper water, sanitation, many people living with friends, family, wantoks – people in one house,” says Sobi.

“I think malnutrition has always been here, but it’s now growing in proportion with the growing population, urban drift, growing unemployment, the rising cost of living.”

There’s also a strong correlation between education levels and malnutrition, he says. Less than 20% of the female population continues to school beyond primary level.

Access to family planning is also critical, says Sobi, but state health services have broken down across much of the country, and many communities rely on cash-strapped Catholic health services, which won’t provide contraception. Population growth is estimated to be more than 2% a year.

“From the health side if we look at these issues, we’ve got to be more proactive than we are at the moment,” says Sobi. “We need to educate the community … But to do it, it needs a lot of resources.”

Low-cost interventions that yield extremely high returns include vitamin supplements and malaria prophylaxis for pregnant women, breastfeeding education and support, deworming, promoting good sanitation and hygienic practices, and providing access to clean water to prevent diseases that compromise nutrition.

The PNG government has recognised these issues, says Namusoke. In 2017 a strategic action plan was resolved to roll out nutrition programmes across education, agriculture, planning and health sectors. But “we need energy, we need consistency, we need support”.

At the same time the long-struggling PNG health system appears to be facing greater problems, with doctors sounding the alarm over the breakdown of supply lines of basic drugs and vaccines.

The scale of the undernutrition challenge is such that the PNG government can’t tackle it alone, says Hurney of Save the Children.

Despite what her report describes as overwhelming evidence of the efficacy and cost-effectiveness of investing in nutrition programmes, they are not given priority by PNG’s largest donors. The latest available data (from 2010-2012) indicates that Australia, PNG’s largest bilateral donor, directs just 0.1% of its official development assistance to PNG to nutrition programmes. Most emphasis is on projects promoting human and economic development.

“You cannot promote sustainable economic growth if around half the country’s population of working age continues to suffer from undernutrition in childhood,” Hurney says.