Focus on malnutrition

Sita Maya Lama never realised how malnourished her five-year-old son Arjun had become until he collapsed from severe chest and stomach pain last week. Weighing just 9.5 kg, Arjun had become so weak that it even shocked staff at the Nutrition Rehabilitation Centre (NRC) in Nepal, that has nursed back to health over 1,000 children from malnourishment over the past six years. “I did not realise how weak my son had become. I have been so neglectful,” explained Sita, who migrated from Udaypur, a poverty-stricken district about 350 km southeast of the capital, Kathmandu, to start a new life. She took a job in a carpet factory where she spends 12 hours a day and does not even have time to feed her only child. Rural Malnutrition But Sita is lucky to have access to the NRC, which will help nourish her child and make him healthy again in less than five weeks. Large numbers of women in food-deficit and impoverished remote districts of the Himalayan kingdom have to rely on local health posts without the benefit of trained nutritionists. “Global studies have shown that malnutrition is an underlying factor in 55 percent of all child deaths. Since the rates of malnutrition are very high in Nepal, worse than parts of Africa, we can assume that the situation is similar or worse," Per Blomquist, a nutrition officer with the UN Children’s Fund (UNICEF), said in Kathmandu. According to the Nepal Human Development Report (NHDP) for 2004, nearly 63 percent of children under five suffered from chronic malnutrition that exacerbated curable diseases like diarrhoea, measles and acute respiratory infection (ARI) from which a large number of children die every year. The Ministry of Health (MoH) reported that diarrhoea alone causes an estimated 30,000 child deaths every year. Another government report revealed that ARIs affected nearly a million children all over the country. Lack of support to tackle malnutrition “Malnutrition has not yet attracted enough attention unlike Vitamin A, anti-measles and deworming campaigns, because the health programmes related to it do not yield visible and immediate results,” Dilli Raman Adhikari from the MoH’s Child Health Division (CHD), said. Many health experts like Adhikari involved in child nutrition programmes are concerned that aid agencies have not previously paid much attention to the issue. Even the government has yet to treat this major public health issue as a priority. Nutrition experts say that though there is some funding support for nutrition projects, the focus is more on micro-nutrient deficiencies such as Vitamin A, iron and iodine and less on protein energy malnutrition, also known as PEM, which is a bigger problem, they say. Past reports suggest that it is also responsible for 70 percent of child deaths through related illnesses. PEM, caused by low food consumption, is linked to poor mental and physical development. It accounts for over half the number of cases of stunted growth among Nepali children - irreversible after the age of two. According to UNICEF’s ‘State of the World’s Children’ report for 2005, about 48 percent of children under five suffer from being underweight and 51 percent are stunted in Nepal. More programmes needed “The government has to introduce more nutrition facilities at hospitals and programmes to specifically deal with malnourished children,” explained Som Paneru from the Nepalese Youth Opportunity Foundation (NYOF), which runs the nutrition rehabilitation centres in Kathmandu and has also started nutrition wards in two zonal government hospitals in east and west Nepal. The organisation is lobbying the government to introduce more nutrition wards in medical facilities so that doctors and medical personnel are educated and adequately trained on treatment methods for malnutrition. “Most of the time, sick children are discharged from hospitals after treating their other diseases, but there is neglect of their malnourished state. This causes illnesses to reoccur and leads to other diseases, often leading to the child’s death,” added Paneru. Prevention better than cure But health experts say that the focus should now be more on prevention of malnutrition, rather than trying to deal with the health consequences. They blame illiteracy, ignorance and parental neglect of children as some of the main causes of malnutrition. “Awareness is still lacking about how long to breastfeed the child and when to start giving supplementary food. Lack of knowledge is a dangerous threat in itself,” explained Manisha Bhattarai from the NRC. According to the government's CHD, many rural women are unable to breastfeed their infants for more than two months and start supplementing their children’s diet with other food. “Intestinal problems lead to diarrhoea and other diseases develop when mothers start early feeding of solid food that is indigestible to infants,” explained Adhikari. Another serious problem is poor hygiene practices amongst many parents who feed their children without washing their hands. “Malnutrition problems should be dealt with by a multisectoral approach in which health, education and agriculture play important roles,” added Adhikari. The government started a joint nutrition support programme in 1985 when the health, education and agriculture ministries were all involved and supported by several donor agencies. Later, there were shortcomings in coordination between the government departments and the programme was phased out in 1990. Impact of the current conflict Some nutrition experts are concerned that malnutrition has been made worse by the Maoist conflict that has been dragging on for the last nine years. “The constant migration and displacement of villagers has made the problem even worse, because especially, it is the children who have to change their food habits once they arrive in the cities,” said Pradeep Silwal from World Vision International Nepal (WVIN). WVIN has been working in several food deficit districts and villages where they operate nutrition projects. Silwal maintained that many parents could not afford fresh vegetables or enough rice, leaving the children to satisfy their hunger with low-protein, dry and non-nutritious foods. “Once the children are displaced in the capital or other major cities with their parents, there is negligible childcare as parents are often away from home working in the factories and other low paid jobs where they hardly get a break to eat themselves,” explained Paneru. A report by the NHDP said that even in the capital, Kathmandu, there were chronic malnourishment rates of over 50 percent in children under five. The malnutrition situation is particularly serious in many parts of the mid-western region, which are badly affected by the Maoist insurgency, with Humla district having the highest rate of malnourishment, according to a recent study by WVIN. “Lack of scarce food due to constant road blockades is already causing a genuine crisis, especially in areas where there is a lack of arable land,” Indra Baral, a nutrition worker from WVIN, explained. According to the NHDP report, nearly 90 percent of children in Humla were suffering from chronic malnourishment and the illiteracy rate was over 80 percent. Many community-based nutrition projects playing a key role in controlling malnutrition have already been closed down in several districts, according to Paneru. “The problem is definitely getting worse now because the remaining nutrition projects are gradually phasing out as more organisations are shifting towards more conflict-related humanitarian projects,” said Paneru.