MALNUTRITION: MADAGASCAR: Poverty and malnutrition on sisal plantations

AMBOASARY SUD, 23 June 2011 (IRIN)



 Photo: Hannah McNeish/IRIN
Lambo, 3, with his grandmother and mother

At the Centre for Treatment of Acute Malnutrition with Complications (CRENI) in the town of Amboasary Sud in the Anosy region of southeastern Madagascar, Samina Tahiaritsoa, 20, cradles her son, Lambo, 3, who still weighs less than six kilograms after 10 days at the centre.
According to the UN Children's Fund (UNICEF), two out of three Malagasy live in poverty and 50 percent of children younger than five have stunted growth due to malnutrition.
Tahiaritsoa is nine months pregnant with her third child, but has only a tiny bump to show for it. Her US$15 salary from working 10 days a month on a local sisal plantation must support the 20 members of her household, who get by on one small bowl of corn each a day and eat meat just once a month when she gets paid.
Already one of the world's poorest nations, Madagascar’s protracted political crisis has deepened poverty. In the drought-prone south, the increasingly unpredictable climate is pushing the risk of acute malnutrition among children even higher, particularly during the "lean season" between October and March when food is scarce.
"When you have a drought, an emergency, prices of food go up and a child doesn't get fed, or gets fed very little over a short period of time," said UNICEF spokesperson, Shantha Bloemen.
Prices of cattle and goats fall during a drought, as households sell off their livestock and eventually resort to consuming seeds and tamarind mixed with ash to survive.
UNICEF supports 49 centres for treating severe malnutrition across the island. A chart at the CRENI in Amboasary Sud shows that around a third of the 130 admissions in 2010 occurred between March and May (the end of the lean season), but local doctors say drought is a cyclical problem affecting the region every few years, while other longstanding social and economic problems are a constant threat to food security.
Children are admitted to the CRENI after weight-for-height measurements determine they are suffering from acute malnutrition. Another centre for acute malnutrition without complications (CRENAS) is attached to the health clinic in Amboasary Sud.
Bloemen said chronic malnutrition is usually caused by poor feeding practices over a period of time, like not exclusively breastfeeding for the first two years of a child's life, or a lack of protein and other nutritious foods in their diet.
"They'll grow, they won't die, but they basically won't ever grow to their proper full size, and it can affect their mental development," she said.
"Above all, it's the poverty that's causing this," said CRENI's head doctor, Samuel Rasaivaonirina, adding that most wage earners support an average household of 10 people on just $10 a month.
They usually earn this paltry living either from small-scale farming or working on the sisal plantation that stretches for kilometres outside the town and has remained in the hands of its French owners since Madagascar gained independence from France in 1960. In an area with over 220,000 people, the plantation takes up 80 percent of arable land in five of the 16 communes (villages).
"The people in these five communes are always poor, always in difficulty. Even in prosperous times for the rest of our region, they are food insecure," said district doctor Andry Rabetsivahiny. "The proof is that in our CRENAS, almost 70 percent of the children admitted come from the sisal-growing areas."
Clinic staff and community health workers trained to identify malnutrition refer children to the CRENAS, from where the most severe cases and those with complications are sent to the CRENI. Rasaivaonirina said children normally spent 10 days in the CRENI and after gaining sufficient weight, were moved back to CRENAS, where mothers and children are provided with support and education.
They also receive supplies of Plumpy'nut - a ready-to-use therapeutic food - to take home. This highly nutritious peanut paste containing micronutrients plays a vital role in an area where 60 percent of the people live more than 5km from the nearest health centre.
Lambo’s severely malnourished state has made him vulnerable to a diarrhoeal infection and he has lost weight since entering the CRENI nine days ago. He will need a course of antibiotics before he can make progress and be discharged. Such complications, which are common in children whose immune systems have been weakened by malnutrition, can quickly lead to death if left untreated.
Rabetsivahiny noted that local "fady", or taboos relating to eating certain foods, has contributed to widespread protein deficiency in an area where meat is an unaffordable luxury for most.
"Children are forbidden from eating eggs and chicken, and sweet potatoes can only be eaten as soon as they are dug up," he said. Chickens are considered "dirty", and eggs are believed to make women and children mute.
He added that men in the area often have numerous partners and are considered wealthy according to how many children they father. The result is large families, often headed by single mothers who struggle to earn enough money to support their children.
Tahiaritsoa was only able to breastfeed Lambo and her other child for two months before going back to work at the plantation. Now, with another child on the way, it seems even less likely she will be able to feed her ever-expanding family.
http://www.irinnews.org/report.aspx?reportID=93050

MALNUTRITION: Niger between two seasons of hunger

04 Feb 2011
Despite the large-scale response to the nutritional crisis from Médecins Sans Frontières (MSF) and many other organisations, tens of thousands of children suffered from malnutrition in Niger in 2010. In spite of better harvests, 2011 also looks set to be a critical year. I travelled to the Zinder region, in the east of the country.



  © Philippe Latour
Village elder Salouf Kina and his son Abukar discuss the latest village events.

Around a hundred years ago, the father of Salouf Kina, 80, founded the small village of Gueza, three hours' drive east of Zinder, the former capital of Niger.
"He was taking his cows to a new grazing ground and decided to settle here with his family. There was plenty of greenery and water here at the time. I've always lived here, but this year [2010] is the worst I've seen," he recalled with a faltering voice.
Today, Gueza, with 2,000 inhabitants, is a patchwork of mud huts built along sandy streets, where the odd tree provides some rare shade. In the surrounding area, a few scrubby fields of millet left over from the recent harvest give the hills an air of neglect.
Salouf Kina's son, Aboukar, has been one of the village wise men for more than 50 years. Aboukar, who is also a neighbourhood chief, tells of the terrible lean period that the inhabitants of Gueza experienced in 2010.
"At the end of 2009, the harvests were very bad and some families harvested nothing at all because of the drought,” he explained. “When people's stocks ran out and they could no longer borrow, they had to leave the village - young men at first, to go and work in Nigeria, then whole families.
“Between May and September, more than half of the village fled, leaving behind only women, young children and the elderly. We're a long way from everything and few people are interested in us. If MSF hadn't set up a feeding centre at the health centre, all of us would have left and the village might have died."
Gueza's Integrated Health Centre is one of the only concrete buildings in the village. It is the young Mamane Bashir, the centre manager, who greets us. During this period in late December, there were few consultations and MSF had packed up its out-patient nutrition education and rehabilitation centre for cases of severe malnutrition (CRENAS). It is hard to imagine that three months ago some 300 children were being treated by the MSF team here.
"The rains came very early this year and the malnutrition situation was exacerbated by malaria, which hit the weakest children,” explained Bashir. “Last August, we treated around 600 children, compared with just a hundred or so in August, 2009. This is also linked to MSF's presence, which ensured that the medicines and therapeutic foods didn't run out."
In Zinder and Magaria, the main towns in this region of Niger, at the end of December, there are still some 200 children in the beds of the CRENIs, the intensive hospitalisation centres set up by MSF for the most serious cases of malnutrition. However, these facilities - rows of beds under large tents - now seem relatively empty. At the height of the nutritional crisis, in August and September, more than 800 children were being treated there, the majority of them on the brink of death.
Kelima, 32, and a mother of four, took her youngest child, Djamilou, aged 15 months, to the Zinder CRENI in early December. He had lost a lot of weight. The MSF doctor diagnosed him with severe anaemia combined with malaria. After being immediately put on a drip and then fed therapeutic foods, he gradually gained weight. Two weeks later, he smiles and waves his hands when spoken to. "Soon we'll be able to go back to the village" explained Kelima, relieved. "But this year, it was really too difficult to feed the children; there were only a few handfuls of millet for the whole family...".
"Unfortunately, 2010 was the year that broke every record,” underlined Dr Moïse Moussa Gabrial, head of the Magaria CRENI. "Since January 2010, we've seen more than 6,200 children. At the end of August, we had around 500 hospitalised children. We had planned to recruit and train medical staff, but the situation was so bad that we had to hire people locally and train them on the job.
“At the height of the malnutrition crisis, 280 people were working for MSF at the CRENI. And tragically, we saw the deaths of many children - 133 in September alone - who had arrived in a desperate nutritional state and were often suffering from malaria".
However, 2010 was also the year of unprecedented mobilisation to fight famine in Niger. The government, born of a coup d'état at the beginning of the year, made food security one of its central causes and called upon international organisations to help. A number of organisations, including MSF, provided extensive support for care facilities and implemented large-scale prevention strategies, particularly based on appropriate food supplements, making it possible to limit the damage.
"We dare not imagine what would have happened if no one had rallied to help", explained Patrick Barbier, MSF's Head of Mission in Niger. "But what worries us today is that, despite some good harvests at the end of 2010, 2011 still risks being a very difficult year, in a context which remains one of extreme poverty, often combined with a lack of access to care.
“In nearly all the country's regions, families are heavily in debt and must now, after the harvest, pay back three or four measures of millet for every two borrowed. Added to which, many families’ livestock assets have been reduced from a whole herd at the start of the year to just a few goats and sheep. International organisations and aid agencies must remain extremely vigilant and prepare to intervene on a large scale again in 2011."
In Gueza, Salouf Kina's grandson and Aboukar's son has just turned 20 and already has the serious face of an old man. In a few days, he will set off for Nigeria to sell tea in the street to enable his family to survive in the village and keep the hope that a life there is still possible alive.
http://www.msf.org/msf/articles/2011/02/niger-between-two-seasons-of-hunger.cfm

MALNUTRITION: Niger: Malaria and Malnutrition—a Deadly Spiral

November 15, 2010


Niger 2010 © Halimatou Amadou

Mothers and their children wait inside the outpatient nutritional rehabilitation center in Dan Issa, Maradi region. Malaria is particularly dangerous for malnourished children and the cases of malaria are flaring right now during Niger's rainy season.
Doctors Without Borders/Médecins Sans Frontières (MSF) teams in Niger are particularly on alert during the rainy season between July and November. Malnourished children are at risk of contracting malaria and many who are already suffering from it become extremely vulnerable as a result of the combination. Malaria further reduces appetite among these children, weakening them even more and creating a deadly spiral from which it is difficult to escape. During this year’s rainy season, MSF has treated nearly 130,000 children with malaria in the Maradi, Zinder, Tahoua and Agadez regions.
Like many other mothers, Zainab has crossed the borders of northern Nigeria into Niger with her 16-month-old daughter. They have traveled nearly 125 miles (200 km) to reach the outpatient nutritional rehabilitation center (CRENAS) in Dan Issa. "My daughter had convulsions and we set off yesterday. We first took a cabou-cabou (motorcycle taxi) and then three bush taxis," Zainab said. When they arrived, a nurse performed a paracheck test on the little girl, which confirmed that she had malaria. The disease was worsening the child's anemia.
In Niger, malaria outbreaks flare during the rainy season, when stagnant pools of water become breeding grounds for mosquitoes. The mosquitoes bite humans and transmit Plasmodium falciparum, malaria's principle pathogenic agent in the region. By July this year, 8,676 cases of childhood malaria had already been recorded in Madarounfa district. The figure represents nearly 50 percent of all patients—adults and children combined—in this district.
When they arrive at the CRENAS, children are screened and treated at no charge. If a simple case of malaria is confirmed, the child is sent home with a combined treatment. However, if the child is suffering from complicated malaria, such as malaria with neurological manifestations, or develops malaria-related complications such as anemia, hypoglycemia or respiratory distress, he or she is referred to the Dan Issa malaria treatment unit.
Malnourished children who have developed a serious form of malaria, and are thus doubly weakened, are treated at an intensive nutritional rehabilitation center (CRENI). In addition to receiving ready-to-use therapeutic foods, they are also given antimalarial treatment. "Malaria is an additional threat for malnourished children as it leaves them more vulnerable," says Dr. Sibibé, medical director at the Dan Issa CRENAS. Malnutrition creates a relative immunosuppression. The children are at higher risk of developing complicated malaria and lose the energy to fight illness. A child who is underweight for his or her age is thus twice as likely to die as a child whose nutritional status is normal. "One of the reasons that malaria is so deadly is that it causes anemia, just like malnutrition," said Dr. Susan Shepherd, coordinator of MSF's nutrition working group.
Malaria thus ravages Niger. With more than 2 million cases recorded since the beginning of the year—more than twice the number recorded in 2009—the epidemic continues to grow. "The hospitals' pediatric departments are overflowing," said Dr. Laouali, who works with Forsani, a Nigerien NGO, in Maradi. "In certain feeding centers, more than 70 percent of children have malaria." His teams, which have provided support to the general hospital's CRENI since June, are now backing up the pediatric unit's staff, which has been overwhelmed by the surge of patients. At least 150 children have died from malaria in the last two months.
To reduce malaria's terrible impact on the population of children—whether they are malnourished or not—MSF is working on a pilot project in Magaria with the Integrated Health Centers, seeking to improve access to health care. The organization's community workers are educating the populations at risk and are fanning out to villages to conduct rapid diagnostic tests for malaria so that early treatment can be provided—before it's too late and before the child has lost the strength, tenacity and will to hang on to life.
In Niger, MSF runs medical and nutritional programs in the regions of Tahoua, Maradi, Zinder and Agadez.
http://www.doctorswithoutborders.org/news/article.cfm?id=4853&cat=field-news&ref=news-index