Malnutrition in Karamoja, Uganda: "We fear the worst is still to come"

In Karamoja malnutrition is chronic, however this year the remote region of northeastern Uganda is suffering its worst drought in five years, creating a humanitarian crisis. The last two years saw back-to-back dry spells followed by unusually heavy rains. Rising food prices make what food is available in the market simply unaffordable.  The poor rains last year and late rains this year have led to late and insufficient planting of peanuts and sorghum and there is also a rising number of animal losses.

Karamoja is home to a population of about one million, who are mostly dependant on animals for their livelihoods. The region is well known for conflicts connected to cattle raiding. Pastoral-nomadic lifestyles and insecurity make it difficult for the population to access the region's few health facilities. Karamoja's humanitarian crisis is characterised by high levels of food insecurity and heightened rates of acute malnutrition.

In response Médecins Sans Frontières (MSF) opened a therapeutic feeding programme for children under five in the worst-affected districts of Moroto and Nakapiripirit. Kodjo EDOH, MSF head of mission in Uganda explains: "The best way to assist and treat children, the most vulnerable in the population, is to travel out to the villages to find the malnourished kids while providing them with two-week rations to get them through the worst. We fear the worst is still to come". This is the best way to bring care as close as possible to patients and to reach the most vulnerable in the moving nomadic population of Karamoja.

The MSF nutritional intervention started in June 2008 and was expected to run only until September. Now, with almost 24,000 children screened and 2,300 of them severely malnourished, the programme is expected to continue into 2009.

George MBALUTO, the Kenyan nurse in charge of the programme, describes how the mobile clinics for the feeding programme are set up. "The mothers come with their children to sit in the waiting area. Here they are given education on nutrition and personal hygiene." Children between six months and five years are then screened with a mid-upper arm circumference (MUAC) bracelet. "Any child measuring between 11 and 13.5 cm on the MUAC has his weight and height taken. Those measuring below 11 cm as well as those with bilateral oedema [swelling due to fluid accumulation] are admitted directly as they are considered to have severe malnutrition."

Every newly admitted child is tested for malaria and screened for other medical conditions such as infections and diarrhoea. In some areas, 60-90% of the kids were found to have malaria. Two nurses do consultations, examine the children from head to toe and rule out any complications. They look for infections and depressed immunity. The children receive folic acid to prevent anaemia, as well as vitamin A. They receive antibiotics and other drugs to treat complications.

Children who are severely malnourished without other medical complications will be treated on site, while a child who is very sick or has poor appetite is referred to the St. Kizito Hospital in Matany, one of two district referral hospital. Here MSF supports the only inpatient therapeutic feeding centre in the region. Once children are stabilized at the centre, they are discharged and followed by the mobile clinics closer to their homes.

In Karamoja, chronically devastated by malnutrition, many families cannot afford food, let alone the right food, and must survive on cereal porridges that lack essential nutrients. Therefore MSF treats malnourished children with ready-to-use therapeutic food designed to match their needs.

"Here we use Plumpynut, two sachets for children of less than 8 kg and for children over 8 kg, three sachets," elaborates George Mbaluto. "Soap and mosquito nets are provided to help with hygiene and to prevent malaria. A supply of Plumpynut is given to the mothers and they are asked to come back 10 days later. We have not seen many problems, rather some good progress. Most of the children like the therapeutic food and are gaining weight. Although it depends on the location, we see about 60 to 70 patients a day."

The team is encouraging community health workers to seek out malnourished children by visiting families. "So far, the mothers are coming steadily and the turnout reaches 80 to 90% in most clinics. But still, in one or two of them, we are only seeing around 50%, so we have some work to do there."

MSF believes that the challenge in areas most devastated by malnutrition is not only to treat those most affected but also to prevent them falling into the terminal stages of malnutrition in the first place by ensuring that all children have access to nutrient rich foods.