Focus on malnutrition and the conflict

For Goma Shrestha, providing for her children’s daily needs is more than a challenge; it’s impossible. Despite the fact that her one-year old son’s normal body weight should be 10 kg, Babu Shristha, weighs just eight kg, leaving this impoverished mother-of-four in a quandary over what to do. Arriving in the capital Kathmandu from Shinduphalchok district 200 km away, one of the worst affected areas of the decade-old Maoist insurgency against the state, she now lives along the polluted banks of the capital’s Bishnumati River, where she cleans houses and alongside her porter husband, earns a combined income of just US $50 a month. “Life is very difficult for us,” the 35-year-old domestic helper said. “I would like to do more, but I can’t.” THE PROBLEM OF MALNUTRITION That’s a fundamental problem for many mothers with children in Nepal, where more than 50 percent of all children below the age of three are malnourished. The question, however, is whether the insurgency, a conflict which has already taken the lives of more than 13,000 and displaced thousands more, is now actually making those numbers worse. “The conflict is exacerbating malnutrition levels. Definitely, we can prove it,” said Reinhard Fichtl, country representative for the international NGO Terre des hommes Foundation, which has been working closely with thousands of impoverished mothers and their children in the country for years. “We are doing this since 2001 and it seems that the number of needy families is increasing,” he said, citing an earlier study the NGO had conducted. According to findings published in its “Nutritional Status of Children Victims of the Armed Conflict in Nepal”, a 2005 survey of internally displaced children in Banke district in midwestern Nepal, of the 264 children under the age of three surveyed from four project locations where IDPs families were living, 59 percent were found to be underweight and up to 15.9 percent wasted. The highest number of malnourished children were found in the Rajhena internally displaced persons (IDPs) camp (73 percent) near the southern border city of Nepalganj. At least 55 percent were suffering from common illnesses like diahhorea, fever, acute respiratory infections and skin ailments, the report said, adding malnutrition rates and prevalence of common illnesses (82 percent) in small children, especially in Rajhena, could be considered as worrying. THE HISTORY OF MALNUTRITION But malnutrition is nothing new in the impoverished nation of 28 million. Even before the start of the conflict in 1996, malnutrition levels in Nepal’s central mid western districts stood at between 60 and 65 percent – a key indicator of chronic underdevelopment.

A mother and her baby in a village outside the capital, Kathmandu

Today that situation is worsening, Fichtl asserted – particularly among children between the sixth and sixteenth month of life, many of whom will never become strong adults or become resistant to diseases, are susceptible to stress, and may even die young. During this critical age in a child’s development, a large number of calories are needed to support the child’s growth, otherwise the child may be permanently stunted – a condition generally determined in the first two years of life – and largely evident in the country’s population. The United Nations Fund for Children (UNICEF) reports that 50 percent of children in the mountain kingdom are stunted, referring to those children as short for their age, with that figure rising to up to 80 percent in mountain areas. “Malnutrition is one of the most challenging tasks in a country like Nepal and its worsening because of the conflict,” Fichtl repeated. And with little improvement over the past three decades, the veteran aid worker might just be right. “We now even have the problem that many donors don’t want to fund malnutrition projects because the success rates are so low,” he said, emphasising the need for patience and many years before real results can be achieved. THE GOVERNMENT’S POSITION Yet waking up to that reality is not always easy. Malnourishment in the Himalayan kingdom is a contentious one, particularly for the government which only recently claimed that they had made significant inroads in malnutrition-related problems in recent years, despite facts to the contrary.

Malnutrition has been a problem in impoverished Nepal for decades

Speaking at an orientation programme for media professionals on the role of nutrition in the attainment of the country’s Millennium Development Goals (MDGs) in March, Dr Yahsobardhan Pradhan, director of the Child Health Division of the Ministry of Health and Population, said that a concerted effort by government and other partner agencies had made it possible that Nepal could raise its head in the international forum in its campaign against malnutrition. But that may be premature. Malnutrition among children in Nepal remains a major cause of child mortality, claiming around 50,000 children each year. “Apart from malnutrition being the underlying cause of child mortality, it impacts on child growth and mental development, thereby affecting social and economic development,” Pradhan was quoted as saying, a sentiment echoed by his colleagues. Sharda Pandey, chief of the Nutrition Section of the Child Health Division, said malnutrition had proven a multi-dimensional problem, related to education, economy and levels of awareness. “Good nutrition is a fundamental right for all, for survival, growth and development,” she added. Sadly, however, that is a right many still do not have; a fact that should make those in the donor community stand up and notice, aid workers say. “It’s absolutely unacceptable that we have malnutrition levels above 50 percent. And in Nepal, it seems to be accepted,” Fichtl argued, noting many donors still failed to understand the problem’s complexity. Nutrition programmes have to be social programmes which are interrelated to the empowerment of women in marginalised communities to increase their level of decision making at home, access to food, along with access to money and resources, he explained. According to another study by the NGO two years earlier, the primary cause of malnutrition amongst children in Nepal is the stress of mothers, many of whom have to work or lack enough time to concentrate on the child’s actual needs. “Very often they do not realise how much attention a small baby needs and they simply forget to feed it,” Fichtl explained, stressing the fact that malnutrition was not always related to food shortage. Most of the malnourished children cited in the NGO’s 2005 report came from female-headed families and knowledge among mothers on the feeding practices of small children seemed limited. Moreover, only one of the 18 mothers surveyed said she fed her child five times a day while others fed much less. Whatever little food they had access to, many mothers were not aware that these very food items could be prepared nutritiously for their children, while none of the mothers prepared separate food for their children. Indeed, at least in Nepal, malnutrition is very often related to stress symptoms brought upon the family by the ongoing conflict, Fichtl added, particularly with regard to displacement or the absence of a husband or male family member who may have migrated abroad for work. Upwards of 80 percent of all children surveyed below the age of three at the Rajhena IDP camp were sick, caught up in the traditional conflict scenario in which disease causes malnutrition and malnutrition causes disease, the report noted. “So many children are caught in this vicious cycle and unfortunately many people, including many NGOs, don’t see the relationship between the conflict and malnutrition,” Fichtl asserted.

Terre des hommes country representative, Richard Fichtl, says the conflict is making malnutrition levels even higher

Following a recent visit to the mid-western districts, he was appalled by the lack of health posts in the area, saying: “There is nothing. Outside the district headquarters, health posts were nonfunctional.” “When we talk about malnutrition, it needs a constant interaction between health workers and affected families. That system has gone and it’s very difficult to reestablish such a system in the framework of health because you need health workers, you need coverage, you need social interventions – all of which are particularly difficult in Maoist-controlled areas,” he further explained. A NEED FOR FURTHER ASSESSMENT Others, meanwhile, are less convinced that malnutrition levels as a result of the conflict are actually rising. “Malnutrition is a disaster in Nepal and has been forever,” Po Blomquist, chief of UNICEF’s nutrition and care section in Kathmandu, said, noting that although one would think that the situation is deteriorating further, they had not seen any conclusive evidence of that happening. If body weight or body wasting were used as indicators, the figures could be misleading, Blomquist said, depending on the season. “Trends such as stunting are a better indicator. Stunting does not change with the time of the year, while wasting goes up and down,” he clarified. Moreover, women in Nepal are often very short already or malnourished during birth which in turns results in babies having a low birth weight as well – or who inherit malnutrition. “This is not to say that there might not be localised examples in which malnutrition rates had worsened because of the conflict. [But] we don’t see anything strongly suggesting that the rates are increasing,” the UNICEF official stressed.