Sparse rainfall in 2011 triggered food alerts for Mali which went out well before the start of the rebellion in the north in January, and the coup d'état in Bamako in March. This year, the rains have been better but the warnings from the north, in particular, remain stark particularly for food insecurity and malnutrition.
"We have been confronting a major nutritional, humanitarian and security crisis," said the head of the Malian Red Cross, Abdourahmane Cissé. "A lot has been done, but it is not sufficient. Promises have been given, but how many have been kept? People are frustrated."
Current relief operations in the north are taking place against a background of speculation about military intervention, with the prospect of a rejuvenated Malian army partnering troops from the Economic Community of West African States (ECOWAS) to take on the different Islamic movements that hold sway in Gao, Timbuktu and Kidal.
Relief organizations talk of the need to work through different scenarios, with Oxfam warning: "Any military action needs to be carefully planned so it does not cause more suffering to Malian civilians." But for now, the main focus remains on delivering food and medical assistance to a population whose resilience has been undermined by waves of displacement, serious food shortages and the traumas and uncertainties of a bitterly fractured homeland.
Access to communities difficult
NGO Médecins du Monde (MDM), active in the north for more than a decade and now with over 250 staff supporting more than 20 health posts, including Kidal hospital, says NGOs have to get beyond the main towns and villages and reach more vulnerable communities in outlying areas.
"Very few NGOs have re-started mobile operations, although this is needed to reach the most vulnerable," Olivier Vandecasteele, head of MDM operations in Mali, told IRIN.
A mass vaccination campaign combined with nutritional screening and support run by MDM covering Kidal region in early September represented a shift of emphasis away from the cities and established health centres, according to Vandecasteele. A second vaccination campaign and nutritional screening is planned in the Ménaka region, near Gao soon.
Nutrition NGO Action Against Hunger says security has limited their nutritional screening and treatment to hospitals and health centres in Gao region, and they only now feel able to make inroads into community work again in water and sanitation, said nutrition coordinator Abdias Ogobara Dougnon.
Several NGOs and UN agencies, including the World Food Programme, significantly cut back their work in the north following the rebel takeover.
WFP has managed to deliver food to 148,000 people in recent months and plans to expand operations once again.
According to the Red Cross's Cissé, the health and nutrition situation is far more critical in the Community Health Centres (CESCOMs) strung out across often inaccessible areas of the north, than in hospitals in town centres. "With the CESCOM, it's the only option most people have", Cissé emphasized. "But there are now so few medical staff in place and it is very difficult to know what has happened with them."
He said the lack of access to remote areas made it impossible to get a real idea of how many people had died during the crisis.
Health indices are alarming. A recent MDM survey in Kidal revealed rates of 13 percent global acute malnutrition, even among nomadic, pastoralist communities with traditionally better resistance. This is more than double the 2011-2012 figure. "That is something that has never been seen before," said Vandecasteele.
“The combination of malnutrition with malaria, particularly among children, is a deadly mix,” Vandecasteele told IRIN.
According to UN estimates, 4.6 million people in Mali remain at risk of food insecurity, 1.6 million of them in the north. Cissé echoes warnings from other agency chiefs about continuing shortfalls in food aid in the north. "We have to get more supplies to people: rice, sugar, oil.”
Negotiating with rebels
Despite a continuing dialogue with the leadership of the main Islamic movements in the north: Ansar Dine and the Movement pour l'Unicité et le Jihad en Afrique de l'Ouest (MUJAO -Movement for Unity and Jihad in West Africa), Cissé hinted that the Red Cross's access and activities were compromised by hostility towards its insignia. "We never had this problem in Mali in the past, but the Islamists do not like the cross, seeing it as a Christian thing."
He noted that Red Crescent organizations from Qatar and Algeria had been much better received.
Vandecasteele said MDM had never been blocked from going where it wanted to go, or had its supply trucks impeded. But he highlighted the need to persuade all parties in the conflict to acknowledge the neutrality and impartiality of humanitarian actors.
Serious logistical headaches remain, however. For example, MDM's concerns include ensuring that critical vaccines are kept at the right temperature on the long, tortuous journey north from Bamako.
"A journey that should take three to four days can now take a week or 10 days", Cissé complained. He talked of the reluctance of truckers to head north and the continuing security hazards on roads and rivers, where motorized pirogues bearing supplies have come under attack from bandits.
Mixed food outlook
Mali is now in the lean season, a time of exhausted food stocks with the population waiting for harvests in October and November. But there are already caveats from USAID's Famine Early Warning System Network (FEWS NET) and others about a major slump in rice production in some areas. Other crops, too, could perform badly, with so many farmers away from their fields at planting time.
There are also warnings of a locust epidemic - particularly in the Kidal region, with prevention mechanisms falling short. The government, deprived of international cooperation, had no means to lead the fight back, said Minister of Agriculture Yaranga Coulibaly.
"All the equipment we had was looted; our vehicles were appropriated;, our staff returned to Bamako."