The changing of seasons affects the lives of people differently throughout the world. For most of my life the changing of the seasons brought forth a sense of excited anticipation for whatever the upcoming season might bring.
In Chad the seasons can be divided by the weather, or by the epidemic. There is the meningitis season, the cholera season and the malnutrition season – all of which overlap to some extent. At the moment the meningitis season is here, and the peak season for malnutrition is slowly approaching. The signs of the changing of the seasons surround us, and the excited anticipation formerly brought forth by the changing of the seasons seems to evade me.
The numbers in Massakory’s malnutrition program grow progressively each week. Not only are the admission numbers increasing, but the types of admissions are changing. In the past month we started to see a growing number of children returning to the program. We can cure a child of malnutrition, but we don’t seem able to cure the country of the problem – children leave the program and go back home to the same problems that caused the malnutrition in the first place.
This week I met 22-month-old Abdoulaye and his mother. Abdoulaye had been in the malnutrition program last summer. He was ‘cured’ in September, only to become sick with diarrhoea in January. He and his family live a 2 ½ hour walk from the nearest health centre. As his mother had to tend the fields to ensure that the family had food to eat, she was unable to take Abdoulaye to the health centre. He progressively got sicker, until he became malnourished again. He re-entered the ambulatory malnutrition program in February. This week when I met him at the malnutrition centre he had met his target weight and was yet again considered ‘healed’ or ‘cured’. When we told Abdoulaye’s mother that he was now healed, and she would not have to return the following week she became angry. ‘And what now – wait until he gets malnourished again?’ she replied.
MSF is currently conducting operational research in Massakory, on the use of Plumpy Nut’s brother ‘Plumpy Doz’, which is a supplementary food aimed at preventing malnutrition in children 6 – 24 months of age. For the next year, in the region where Abdoulaye lives, there will be monthly distributions of Plumpy Doz in the villages for every child that fits the age criteria. Mothers receive four pots of Plumpy Doz a month, and are instructed to give their children three spoonfuls three times a day. I reminded Abdoulaye’s mother of the Plumpy Doz. This did not diminish her anger. ‘And when the Plumpy Doz distributions are done. When you are done studying us? What do we do? Wait until our child gets sick and becomes malnourished again?’ she retaliated. I had no answer. What is the answer?
The discussion took me back to Djibouti and the first time I encountered mothers it seemed might intentionally be starving their children to be able to get access to free medical care. It reminded me of the mothers in Niger who seemed to keep one of their children constantly malnourished so they could receive a weekly ration of Plumpy Nut, with which they fed the rest of their children. I was reminded of the mothers in the Congo who had to make the unimaginable decision of whether to go harvest in their fields, where they would be raped, or to stay at home, not get raped, and have their families starve.
The causes of malnutrition are complex, as is its treatment. Clinically it is not complicated, but socially, politically and economically it is extremely challenging. Plumpy Nut and all of its brothers and sisters are not the long term answer. When leaving the centre with her final week of Plumpy Nut ration, Abdoulaye’s mother bade us farewell and cynically, yet realistically, called out, ‘See you in a few months’.
It reminded me of the end of the summer camp season when I was young. The end of camping season would bring tears to all of the campers and the shared hope that we would all see each again the following summer. The beginning of the peak malnutrition season has barely begun, but I already know that by the time the end appears, many tears will have been shed, and I will hope with every ounce of optimism that we will not have to see again at the malnutrition centre the children that we have treated this season. I can hope... but hoping has its limits.
Images show some of the mothers at MSF's nutritional feeding programme in Massakory, 2012.