Bamako/Mopti — At Koutiala reference hospital in the Sikasso region of southeastern Mali, 300 children are crammed into one room, most of them attached to drips while they receive blood transfusions to treat severe malnutrition with complications, usually malaria. "Even after several years here, I'm taken aback when I see them," said Johanne Sekkenes, head of NGO Médecins sans Frontières in the capital, Bamako.
This is nothing new. Last year, 12,000 children were hospitalized in Koutiala, mainly for a combination of malaria and malnutrition, while the local health centre handled 85,000 consultations. "There is no paediatric hospital anywhere in the Sahel that's big enough to treat these kinds of numbers," Sekkenes said.
The hospital was not built to house 300 in-patient children, but when malaria infection is at its highest during the peak of both the rainy and lean seasons, it can squeeze in 350 if it has to. "The bulk of our work lasts three to six months," Sekkenes noted. MSF treats acutely malnourished children with and without complications at five community health centres and one reference hospital in Koutiala.
The UN World Food Programme (WFP) estimates that 1.7 million Malians are at risk of severe hunger this year due to drought, high food prices, poor terms of trade for animals, and conflict-driven insecurity. Malnutrition rates are sharpened by these factors, but they are always unacceptably high in Mali.
The 2011 government nutrition survey (called a SMART) reported 150,000 acutely malnourished children, and MSF estimates that aid agencies and the government cared for 30,000 of them. "What happened to the rest?" Sekkenes asked.
The North: Kidal "not normal"
It is difficult to know the extent of malnutrition in the northern territories of Kidal, Timbuktu and Gao, which are under the control of Al-Qaeda-affiliated Islamist groups. To date this year agency workers have not yet been going out into communities to screen children (active screening), so only those who come to health centres are being screened (passive screening).
"This often gives higher malnutrition numbers... [nonetheless] what we are seeing in Ménaka and Kidal is not normal," said Olivier Vandecasteele, coordinator at Doctors of the World - Médecins du Monde (MDM) - in Mali, the only NGO catering to people's health needs in the Kidal region. "[These are] very high severe acute malnutrition rates."
Malnutrition rates are traditionally lower in Kidal than further south because pastoralist children tend to eat a relatively high-protein diet with significant amounts of milk and meat. But the crises pastoralists are facing - their animals are dying or too weak to sell, access to pasture is limited by natural and conflict-related causes, and cereal prices are extortionately high - all of which are taking a heavy toll on their health.
Humanitarian response in the north has been slow, partly because it is very complicated to work there - requiring distance management, training new staff from scratch, negotiating with people who are often "in charge" simply because they are armed, ensuring that aid is not "siphoned off", and so on - and partly because information about the needs is so lacking, said Vandecasteele.
Despite these complications, speedy scale-up is needed, he warned.
MDM will undertake active nutrition screening next week as part of a Kidal-wide vaccination campaign, but the staff of NGO Action against Hunger (ACF), who are responding to malnutrition needs in Gao further south, said this was not yet possible due to insecurity in the area.
"We don't know the [actual] malnutrition rates", said ACF head Florence Daunis, whose staff in the north are limited to working in the Gao hospital and bigger clinics. "All we know is that we have taken in lots of malnourished children in the reference centres."
A doctor weighs a malnourished child in Mopti
Health capacity in the north has contracted severely since the region was taken over by Islamist groups in April, when many health workers fled and dozens of clinics were ransacked, said Ministry of Health staff.
Moulaye Djiteye, Head of Medicine at Gao hospital, said most his 150 health personnel left and have been replaced by 138 newcomers, mainly volunteers, while the Ministry of Health's head of decentralization, Mamadou Ballo, reports that over a dozen health centres in each northern region - Kidal, Timbuktu and Gao - were pillaged.
A relatively small population in the north means malnourished caseloads are low compared to the south, but "there is still a crisis", and MSF is working on health and nutrition in Timbuktu, said Sekkenes.
Bamako: malnutrition rising
In the south, malnutrition numbers are starting to emerge. The UN Children's Fund (UNICEF) will undertake nutrition surveys (SMARTs) across the south soon. ACF has just released the results of its survey in commune six of the capital, Bamako, which show that 10.3 percent of children aged under five are severely acutely malnourished - up from 8.4 percent in 2011 - while 8.5 percent are undernourished, and 14.7 percent are stunted.
The admission rate of malnourished children to treatment centres is going up by the week, said Abdias Ogobara Dougnon, head of ACF's Bamako nutrition programme, and the size of the city's population means the figures "represent an enormous caseload".
ACF head Florence Daunis said the extent of the malnutrition problem is often hidden in the capital. Emergency food aid and cash vouchers are being directed to some of the tens of thousands of displaced northerners sheltering in Bamako, but not enough is reaching long-term, vulnerable residents. Together, ACF and the International Committee of the Red Cross (ICRC) cover parts of four of the city's six communes. WFP will launch a nutrition project in the capital in September.
Although widespread scale-up is needed, the crisis also represents an "opportunity" for nutrition, given that so many well-qualified nutrition agencies have set up operations across the country, said UNICEF's nutrition manager in Mali, Denis Gamer.
ACF, Save the Children, World Vision, Agronomes et vétérinaires sans frontières - agriculturalists and veterinarians without borders - among others, are working in the south; MSF, local NGO Aliment and MDM are present in the north.
"If they stay [long-term], and can work at scale, we could deal with moderate acute malnutrition here - we could do lots of prevention and lower the caseload," Gamer told IRIN. He wants a country-wide prevention strategy, plans to set up nutrition focal points in each region, and continue a training exercise that has already educated 3,039 government health workers in nutrition.
But to shift from highly active malnutrition responses to effective prevention requires a government that is equally engaged. Currently, nutrition is relegated to quite a minor "division" in the Health Ministry and government nutrition focal points change constantly, while NGOs provide most of the nutrition treatment and prevention. A 2011 nutrition policy has yet to be rolled out. "There is a 'disconnect' between politics and action," Gamer said.
With the health budget of 195 million CFA (US$365,000) facing cuts due to donor suspensions, a moratorium on new investment or new initiatives in most ministries, and a major government reshuffle taking place, nutrition is unlikely to be foremost in policy-makers' minds.
"Maybe donors and the government are not ready yet to take on malnutrition here," said Sekkenes. "It's a huge investment, and it's long-term... maybe they're not yet ready to go that far."
[ This report does not necessarily reflect the views of the United Nations ]