Brickaville — The eastern Madagascan coastal town of Brickaville in Atsinanana region - ravaged by Cyclone Giovanna earlier this year - provided a refuge of sorts for Edwige Solo and her emaciated children fleeing the aftermath of rural devastation caused by the same storm.
Solo and two of her four children were ferried to the town by her former brother-in-law after seasonal agricultural work in the orchards and rice paddies became virtually non-existent - her only means of survival after her husband had abandoned the family.
May and June in the region are usually bountiful with the harvest of rice and fruit, but the impact of Giovanna and the effects of tropical storm Irina during the January-to-March cyclone season destroyed many fruit trees and swamped about 90 percent of rice fields late in the crop's growing cycle.
Solo's youngest child is about seven months old and weighs about 5kg. Both her and her other child, aged about five, were admitted to the Centre de Récupération et Education Nutritionnelle Intensif (CRENI) after the children displayed signs of severe acute malnutrition - badly swollen feet.
The hospital was badly damaged by Cyclone Giovanna and all medical patients are now treated in the maternity ward. While the harvest season has brought some respite to the region's 49 nutritional centres it has far from ended it.
Heriniaina Rakotoarisoa, a doctor at CRENI hospital in Toamasina, the provincial capital of Atsinanana region, told IRIN that during the lean season (from January to March) he treated three cases of severe child malnutrition with medical complications daily. This has since dropped to about the same number weekly.
"Many times, parents don't see that their children are suffering from malnutrition. They only start to take the children to hospital when they develop other problems, like oedema or skin rashes. And often, it's not the parents who bring the children. When there are problems in the family, children often end up living with grandparents or uncles, and these people don't have the means to feed them," he said.
About 8 percent of all children under the age of five in the most vulnerable zones (the arid south and the east, west and north coasts) are severely malnourished, according to the UN Children's Fund (UNICEF). The Madagascar Demographic Health Survey 2008-09 found that stunting - a consequence of poor childhood nutrition - affects half of all Malagasy children under five, the sixth highest rate of stunting in the world.
Breastfeeding not a panacea
Children aged 6-23 months are the most vulnerable, as breastmilk alone does not meet their required nutrient needs. But this is not the whole picture: Nationally it is estimated by donor agencies that about 4 percent of children under six months of age and exclusively breastfed are severely malnourished. In the case of Solo and her children, it is easy to see why, Virginie Razanantsoa, a UNICEF nutritional specialist based in the capital Antananarivo, told IRIN.
"These people are already vulnerable, and then when there is a shock like a cyclone, they don't know what to do any more," she said.
The average stay for treating malnourished children in CRENI is 4-6 weeks. Whereas before the centres used to cater only for children aged 6-59 months, an open door policy has recently been adopted.
"We have children who come in who are two months old and are suffering from severe malnutrition, or those who are 8-13 years old. They all need treatment," Rakotoarisoa said, adding that some families may come back to the centre three to four times in a year. "We have this one mother with four children who can't feed them. We try to give them specialized nutritional supplements that they can take at home, so that the children don't always end up underfed and sick."
According to Rakotoarisoa, food shortages in the Atsinanana region are a recurrent problem, despite the region's reputation for cash crops. "Farmers here still plant on the ancestors' land, but this land has been divided up many times among the children and the grandchildren. So now the plots of land are not big enough any more to feed the family," Rakotoarisoa said.
The Southern Africa Regional Food Security Update for February 2012 notes that 80 percent of Madagascar's 20 million people live on less than US$1 a day and poor households spend 74 percent of their income on food.
UNICEF's dual track approach
UNICEF has a dual track approach towards treating child malnutrition to reduce mortality and morbidity among children under five. A home-based treatment plan provides recipients with ready to use therapeutic foods like Plumpy'Nut, coupled with a weekly visit to a CRENAS (Centre de récupération et Education nutritionnelle ambulatoire pour les Sévères) centre to monitor progress.
Children with medical complications are admitted to CRENI, where they are treated with therapeutic milk Formula 100 and Formula 75. Through this system, UNICEF and its partners are currently treating about 16,000 under fives nationally for severe malnutrition.
"Before, mothers used to come here to the hospital when the children were already severely underfed. The treatment would at least take a month. Now we have the outpatient centres in the communities, so children can receive early [preventative] treatment at home," UNICEF's Razanantsoa told IRIN.
In 2007 the Malagasy government of President Marc Ravalomanana decided to increase the number of nutritional centres from 73 to 488. However, this network has come under increasing financial pressure since 2009 when the international donor community froze all but emergency assistance after branding Andry Rajoelina's ousting of Ravalomanana a coup.
The sharp drop in donor funding has spared few social services, including the Health Ministry and its National Nutrition Organization (ONN) whose budget has been depleted to such an extent that it can no longer pay salaries and provide free meals for families of patients.
Charlotine Marie Louise, an ONN assistant in Brickaville, told IRIN she had not been paid for the past two months and UNICEF has since assumed responsibility for her salary costs.
[ This report does not necessarily reflect the views of the United Nations ]