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.
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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.