I have been trying to get an idea about people’s beliefs on the reasons for malnutrition here in South Sudan and having already asked the clinic staff for their opinions, I ask some of the mothers in our clinic what they feel. I often get the impression that many of the mothers are in a state of denial that malnutrition is the problem with their child;they seem to think that the only problem is diarrhoea or malaria or cough. Maybe this is partly because of the Nuer characteristic of being a proud people.
The first lady I ask is not from this area and the conversation is in Arabic. Her two year old carries all the features of severe marasmus (malnutrition) that you read of in a textbook – wiry hair, thin ‘old man face’, loss of fat resulting in lose ‘baggy trousers skin’. She recognises that her child has malnutrition. She says he has been sick for a long time and they had no means to attend a health facility as until recently her husband had been posted in an isolated area and the family were with him. She however denies it was because of food shortage ‘I don’t even know,all I know is that he was very sick and it was not because of food shortage’. When I question her about the type of food she was giving the child she says she was only giving sorghum as nothing else was available. The lack of protein in the boy’s diet may well be the root cause of his malnutrition. She adds that her husband salary is paid irregularly ‘sometimes our husbands don’t get the money, and then when they do they run away, he also has another wife to support’.
For the next few mothers we are back speaking in Nuer ‘I think my child does not have a problem with malnutrition he is just sick with diarrhoea and vomiting’ offers one mother whose child is currently receiving therapeutic milk through a naso-gastric tube because of poor appetite related to malnutrition. Another soldier’s wife offers ‘we don’t have enough food for all the family, my husband is a soldier and sometimes will not be paid at the right time, it will be delayed for two to three months’. The next lady I try to ask is from the Dinka tribe and speaks neither Nuer nor Arabic and none of the staff around today are able to translate. This reflects the variety of people as well as views we have in the clinic.
In another tukul, I hear different stories. One woman tells me that her child is now malnourished because he was born during a time of insecurity. She is a widow. ‘We were attacked by a militia group (in April 2011), my husband was killed, all our crops were destroyed, our personal belongings were looted, we stayed two months without any food, the children got sick’. The woman explains that she is not from Unity state but a member of the Pojulu tribe. She has not yet received any pension from the government but says she has survived from the generosity of the local Nuer people.
Cows are a big deal around here, a sign of status and also important in settling disputes and matrimonial arrangements. One woman feels a lack of cows is somewhat to blame. ‘In this country people are living different ways of life, some have a lot of cows and food. For us we lack food. If you have a cow children will be drinking milk and be ok’. Maybe this faith in milk is part of the reason for trust in our inpatient programme where we off the special therapeutic milk. Of course cow’s milk can be healthy for children once it is safe and not given to young infants.
I hear one final story in explaining individual reasons for malnutrition. One lady, Elizabeth,* in our TFC stands out. Whilst many of our mothers are teenagers or in their early twenties, she looks much older. Her nine month old son Diew* has Down’s syndrome. This is not the first time he has been admitted to our clinic. It is impossible to know what the future holds for him, none of the facilities a child with his needs should have are available here. Elizabeth* is also a widow. Her husband passed away last year from a sickness she was told was typhoid fever.
Elizabeth* used to live in Khartoum and earned a living there cleaning houses. She moved back here because ‘we were informed by an international organisation that we should go home to vote, that is why we came here’. With her husband dead and her three oldest daughters married off as teenagers Elizabeth* has to provide for the three youngest children. ‘My duty is only to go and collect firewood which I will then sell in the market. Sometimes I will get ten South Sudanese pounds per day (about €2) if I am lucky, other days between three and five. I use the money to buy sorghum and milk for the children. I cannot afford meat, oil or beans’. When she goes to collect the firewood she leaves Diew* in the care of her six year old daughter. She also cannot provide safe water for her family. The water they get is from the river, she filters it through a clean cloth. The nearest supply of clean water is over an hours walk away and most days she does not have time to reach there. ‘This year also I planned to cultivate but my child was very sick so I could not’.
There seems to be many causes of malnutrition here and solving the problem will require many answers. For now in our clinic we continue to see and treat those most severely affected and advocate for broader action so that the situation will improve in time.
*Names changed to preserve anonymity