The baby lies limply in its mother’s arms. It is listless and feverish, its eyes half closed.
A pile of medical cards, documenting the weight and health of each child brought to this outdoor screening clinic for malnourished children, blows away in the wind. No one notices except for a boy, who runs to retrieve them.
As the baby’s mother takes a seat on the plastic rug under the tree that acts as a waiting room, a healthcare worker notices the seriously ill baby and pulls the mother aside. He tells her the baby urgently needs to be referred for medical treatment as this is a nutrition and screening clinic. The mother refuses. “No, I want this medicine,” she insists, pointing at the boxes on the desk.
She’s referring to nut paste, the high protein therapeutic food given to malnourished babies and children, and the reason why most of the mothers have come here. After a heated debate the mother refuses to wait. She storms away from the clinic without either the protein paste or the referral, and a very sick baby in her arms.
The healthcare worker, Joseph Amef from World Vision, sighs. “I can’t force her. I think she had a mental problem.” He’s clearly shaken by it, but he has more than a dozen babies waiting to be seen and more arriving. The programme has screened 27,000 babies and children across Warrap since 2011. He gestures to the growing line of women and children. “Yesterday we saw 30 to 35 babies, all had malnutrition. Twelve were very, very severely malnourished. That’s a typical day.”
The clinic is situated in the village of Angui just outside Gogrial town in the north-western state of Warrap, near the border with Sudan and one of the “non-conflict” states in South Sudan. Yet despite the peace, the state has one of the highest rates of malnutrition in the country. The situation is about to be made worse by a bad harvest last year, caused by a dry rainy season followed by unexpected downpours.
“Food insecurity is a massive problem. Last month the market here literally ran out of food. There was nothing on sale,” says Yadessa Gedeffa, a programme officer with Unicef. “This isn’t seen as an emergency province by donors because there is no conflict, but supplies have to come here by road from Juba and the roads go through the areas where there is fighting, so nothing can get here.”
The situation has been exacerbated by a national economic crisis. Ten months ago, 50kg of maize cost 350 South Sudanese pounds (£40), now it is SSP1,800; 12 bottles of water cost SSP18, now they are 72, says Gedeffa.
“When we go to the bank to get our salary we are told to wait three days because the bank has run out of US dollars,” he says.“Even families with jobs cannot manage.”
Few people in remote Warrap have jobs, mostly with NGOs; the rest are cattle traders or subsistence farmers. Nyibol, 30, is at the screening centre with Aker, her baby daughter. Aker has scars all around her eyes. Nyibol explains these are not traditional tribal marks but cuts made by a faith healer with a razor blade. “The healer said cutting it would make the swelling in her face go away but it has not, so I brought her here.”
Her friend Ajok holds up her two-month-old son Adhel. “The child has a breathing problem, he coughs and vomits and he won’t breastfeed. I don’t have enough milk in my breasts because we don’t have food in the house. I don’t know if he is coughing because of the hunger or because of the sickness.”
If her baby is malnourished she will get the nut paste, but other medical treatment is not offered here. Instead she’ll be referred to a different clinic. But for mothers like her, who have walked for hours to get here, it may not be easy to go elsewhere. Ajok hadn’t realised it was not a medical clinic before she came. And there is no guarantee the baby will get the protein. Nyibol explains: “I can’t give the Plumpy’Nut to my baby and not offer some to my other children. They are hungry too.”
Alana Mascoll, who oversees a food security project for World Vision across seven states in South Sudan, says: “It’s a scary situation. Last year the worst malnutrition rates were all centralised in the conflict zones, but sadly we’re now seeing the rest of South Sudan suffering from food insecurity. Almost all of Warrap is now at the precarious ‘crisis’ level. But we’re trying our best, by setting up vegetable plots and teaching mothers how to prepare foods in the most nutritious way possible.”
Daniel Madut, a social mobiliser for Unicef, makes house visits to advise mothers on hygiene and nutrition. He says: “Lack of education makes the poverty worse. So many babies get sick from diarrhoea and are left covered in faeces and flies. I tell the mothers if they don’t have soap and water to wash their hands then to use ash from the fire. Or if they don’t have a chicken to feed their child to give them pumpkin leaves instead.”
In a compound of five thatched huts, none with sanitation or nearby access to clean water, we meet Yenka and her six children, who play marbles with little rocks. She says: “During the war with the north we had to feed on leaves from the trees. My family depend on what my husband grows but now that is very little. The market is empty. Everyone is expecting a famine and I fear we will soon be eating leaves again. I look at this tree outside my hut and I think soon this is all we will have to survive.”
Madut shows her his nutrition and hygiene presentation, a series of brightly coloured laminated posters showing either smiling or crying babies on topics ranging from hand washing to when to feed a baby solid food. At the end, he asks her if she has understood. She nods.
When asked to explain why feeding a young baby solid food is bad, she replies: “Because the picture said so.” Madut, one of 244 social mobilisers trained by Unicef – two from each village across Kuajok district in Warrap state – says: “The Dinka mix cows’ milk with breast milk and give solids too early. They don’t give water to babies with diarrhoea because they think it makes it worse. It’s very hard for me to convince them this is wrong.”
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