Convincing mothers their children need treatment in Nepal’s isolated rural districts is an ongoing challenge.
“All of my children look like this,” Dharma Bhatt, 26, told IRIN from her daughter’s bedside at Achham District Hospital, in the far west of the country. “I had no idea she was malnourished.”
A local female community health volunteer persuaded Bhatt to walk one hour to the public hospital after 12-month-old Mankala developed classic pneumonia symptoms. Bhatt did not suspect a lack of food was the cause for her daughter's weakness.
With almost half of all children under five stunted and a national global acute malnutrition (GAM) prevalence of 13 percent, child malnutrition is considered a silent epidemic in Nepal, according to the UN Children’s Fund (UNICEF). GAM is the percentage of children over six months and under five years old who have moderate or severe acute malnutrition.
In the country's mountainous western region, where road access is limited, child malnutrition is more widespread.
Achham District has a GAM prevalence of about 18 percent. Its low levels of education and food security, and its remote location present a challenge for health workers, who are struggling to change public perceptions of what constitutes a healthy child and what it takes to recover from malnourishment.
A trip to Achham District Hospital, near the district capital of Mangalsen, can involve days of hiking from some parts of the district.
“We have to beg mothers to admit their babies,” said Krishna Kadayat, a nutrition expert at the hospital, which provides free medical care. “Drop-out rates for follow-up appointments are also very high.”
One programme, the Community Management of Acute Malnutrition (CMAM), implemented through UNICEF and the Nepal government and launched in January 2010, has brought health care options closer to those at risk of malnourishment by creating 26 health outpost centres, but the programme cannot flatten the mountains that lie between most peoples' homes and the hospital.
At the end of the district hospital's crowded, dimly lit hallway one recent Saturday morning, Paan Karishma looked on as her nine-month-old daughter Merina's arm was measured with a circumference tape, one of the diagnostic tools introduced by the CMAM programme. The pieces of tape crossed to indicate red, showing her arm circumference was slightly less than 12cm.
Kadayat, who also serves as a CMAM monitor, silently mouthed “SAM” - severe acute malnutrition, the most advanced and threatening stage of malnutrition.
“Mothers see the tape visually and they understand,” Kadayat later said. “Before the tape we were judging malnourished cases by weight only, which is not the most accurate representation since children can swell.”
At the hospital, Karishma received 42 complimentary packages of Plumpy'nut, a high-protein peanut-based ready-to-use-therapeutic food. She said she would return after 14 days for a check-up and to get more Plumpy'nut.
It is the second time she has visited the hospital, and she reports that Merina does not like the taste of Plumpy'nut. Kadayat says she frequently hears this from mothers who keep the Plumpy'nut at home, or who eat it themselves if their children do not finish it.
She added that some mothers have also told her that their husbands do not like them taking food handouts from foreigners.
Nepal's female community health volunteers (FCHV), estimated to number more than 50,000, play a variety of roles in this community, as they do across Nepal. Since the CMAM project was initiated, they are now responsible for referring suspected malnourished children to the hospital and informing mothers about the benefits of the unfamiliar Plumpy'nut.
But even some FCHVs, who take part in paid training sessions subsidized by UNICEF and the government, do not practice in their own homes what they have been taught.
Kokabita Vishwakarmas, an FCHV from Janalibandali Village Development Committee, said she has not measured her 12-month-old daughter's arm in six months and thinks she is malnourished. She explained that her measuring tape broke.
“She never eats anything,” Vishwakarmas said of her daughter at a meeting of volunteers more than an hour's walk from Mangalsen.
Achham (population 300,000) is among five western districts in Nepal that is hosting the CMAM pilot project, expected to expand after 2012.
This article was produced by IRIN News while it was part of the United Nations Office for the Coordination of Humanitarian Affairs. Please send queries on copyright or liability to the UN. For more information: https://shop.un.org/rights-permissions
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