The Starving Children of Helmand

Province
Already gripped by violence and poverty, Afghanistan is
now in a malnutrition crisis that has left a quarter of its
children underweight and could cost the country millions.

LASHKAR GAH, Afghanistan The malnutrition ward at Bost Hospital in Lashkar Gah is normally packed with
wide-eyed, withered babies and skeletal toddlers with swollen stomachs. But at the moment, only half of the beds
are full.

BY SUNE ENGEL RASMUSSEN-MAY 1, 2015

Thats a bad sign.
Its poppy harvest season in Afghanistans southern Helmand province the time of
year when many rural households secure most of their annual earnings. And that

means a dip in admissions to the hospital: Most women will not travel unaccompanied
from the countryside to the city, and men cannot afford to abandon their work in the
field to go with them. In a few days when farmers have wrapped up this years harvest,
the children who make it to the hospital will be in a much more critical state if they
survive at all.
Farzana, a young mother who doesnt know her age but looks about 16, is one of the
ones who made the journey and when Foreign Policy visited the ward April 6 she
was already impatient to go home. Her husband was also in town, waiting for their 5month-old son, Juma Khan, to get better so they can travel back to their home in Nade Ali district, about 12 miles away away, in time for the harvest.
Juma Khan has been weak since birth, but seven days earlier hed gotten diarrhea
and started vomiting. His arms and legs were shrunken; his dark hair fell in gluey
patches over his forehead, which looked too big for his body. Farzana said she didnt
know why her son was ill, though nurses told her she needed to feed him breastmilk
rather than biscuits, tea, and milk formula.
Afghanistan is in the midst of a malnutrition crisis. While numbers are disputed
because of the difficulties of surveying diseases in remote areas, the best study
available the U.N.-backed National Nutrition Survey estimates that more than
500,000 Afghan children under the age of six will require treatment for malnourishment
in 2015. A quarter of all Afghan children are underweight. If nothing is done, close to
15 percent of those will not survive, says Lakshmi Balaji, deputy representative of
UNICEF in Afghanistan.
At first glance, the children in Bost Hospital look like the victims of hunger and drought
in Niger, Ethiopia, and other developing countries. But Afghanistans malnourished
children are a product of broader political circumstances, and a testament to the
failures of 13 years of international involvement in Afghanistan. Despite an
unprecedented torrent of foreign aid, health facilities remain scarce, education patchy,
and poverty rampant, especially in the countrys south. (The United States alone
has spent more than $100 billion in non-military assistance since 2002, outspending
the Marshall Plan that rebuilt Europe after World War II.) In Helmand province in
particular, where Farzana and her son are from, the effort to eradicate poppy and sow
the seeds of a sustainable agricultural sector one that could support a vibrant
economy, a capable government, and create political stability has been a failure.
Food shortages are not the main factor behind Afghanistans malnutrition problem,
says Guilhem Molinie, country representative of Mdecins Sans Frontires (MSF) in
Afghanistan, who run the malnutrition ward at Bost Hospital. Rather, poor knowledge
about diet and breastfeeding, and misuse of often low-quality antibiotics wear on the
immune systems of Helmands children, making them more susceptible to diseases
that hinder food intake. Worsening violence across the province makes healthcare
facilities largely inaccessible, which prevents education about feeding practices and
dramatically aggravates diseases among children. The prolonged conflict also uproots
families and pushes them into constantly growing communities of internally displaced

people, which nationwide now number at least800,000, and where malnutrition is

particularly rife.
Malnutrition is a very particular disease. Its one of the most complex diseases to
treat, says Molinie. Its a political disease.
Bost Hospital in Lashkar Gah admits between 200 and 250 acutely malnourished
children every month. After stabilizing the childrens condition, they send them back to
local communities via Afghan partner organizations.

Gul Ahmad is four months old, but his face is wrinkled like an old mans. The skin on
his legs sags, too big for his boney limbs, a symptom of marasmus, a form of severe
malnutrition occurring primarily in a childs first year. Other children display signs
of kwashiorkor, a disorder characterized by, among other things, bloated stomachs
and triggered by protein-deficiency.
Less noticeable but equally serious is the prevalence of chronic malnutrition, which
doesnt show the same stark symptoms as acute malnourishment, but can stunt the
growth of a childs mind and body in a way that, after age two, is largely irreversible.
It is maybe not immediately visible, but it affects large, large portions of the
population, and particularly the children, says U.N. World Food Program (WFP)
country representative Claude Jibidar.
According to the National Nutrition Survey, up to 40.9 percent of Afghan children under
six are stunted. Chronic malnutrition on that scale not only affects individuals, but can
hobble the economic development of a country: The World Bank suggests that

malnutrition and stunting of children costs Afghanistan 2 to 3 percent of its annual

income each year in lost productivity and economic growth.
Many Afghans dont understand malnutrition as a disease, doctors say, so parents will
often take their child to the hospital only when he or she catches a virus or infection, at
which point the condition is severe. And when the child is discharged, many mothers
will go back to their previous feeding routines.
Any maternity education that does take place in remote areas is often stymied by
tradition, which isolates women to the confines of their home. It is also hampered by
mothers-in-law who wield huge influence in the house, and who are often reluctant to
change child-raising practices that worked for them, such as feeding children glucose
and aggressively marketed infant formula at the expense of breastfeeding.
What [mothers-in-law] say is law, says Guilhem.
At Bost Hospitals malnutrition ward, for example, visiting relatives often bring tea,
sugar cubes, and biscuits for the child the very diet that might have brought them
here in the first place.
Walking the ward, Amal Ali, a young Canadian nurse, persistently but kindly questions
Suleijah, the mother of a scrawny boy of three months who was suffering from
abdominal pains and diarrhea, what she feeds him. Suleijah says she doesnt have
any breast milk left. How long did she breastfeed for? Ali asks. Two months, Suleijah
says. Did she feed her son glucose? Yes, two or three times a day.
This is very common story, Ali says later. Mothers feed glucose to their children
because they are told it makes them sleep longer. It also relieves the baby of the
feeling of hunger, but provides few vitamins, so a baby fed glucose will breastfeed less
but not get the nutrition that he or she needs. Eventually, breastfeeding becomes
harder for the mother, who quickly gives up trying and switches, when the child is only
a few months old, to milk formula, with the risk of exposing the child to contaminated
water, or cows milk, which lacks iron and vitamins.
Another mother in the ward says her four-year-old son fell ill when she fed him a piece
of kebab from the kitchen table. The emaciated boy has been vomiting, unable to walk,
for 10 days now. The mother says she thinks the kebab was undercooked.
Hamza Atim, medical coordinator for MSF, disagrees. He is severely underweight, he
says. One kebab would not make him wasted like this.
As the Afghan conflict rages on, so does the malnutrition epidemic. In Helmand,
districts beset by violence are increasingly difficult to reach, isolating malnourished
children from proper health care. For instance, hardly any of the malnourished children
at Bost Hospital come from the northern districts of Helmand, where the fighting is
fiercest.
With a deadlocked, money-strapped government in Kabul incapable of expanding
even the most basic of services, health care in the south is largely reliant on foreign
donors. But they cannot root out the problem alone.

Jibidar, of WFP, says that while NGOs have done a lot to improve conditions in remote
areas of Afghanistan, continued conflict and the fragile state of the government makes
it impossible to effectively combat malnutrition.
As long as the services that those people require cannot be sustained in the long run,
the problem will keep growing, he says.
Photos: Andrew Quilty
Posted by Thavam