Feeding The Children
Chris Pesket is a nurse from Norwich. Since July, he has been working with MSF in Kass, South Darfur, Sudan. Interviewed at the end of September, he describes his work with seriously malnourished children and their mothers.
When I finished my nursing training in 1992, I knew I wanted to do this kind of work. Before joining Medecins Sans Frontieres (MSF) in 2001, I had already worked overseas in India and South America. This is my fourth mission with MSF. Previously I worked in South Sudan for 15 months, in Iraq for about 5 months, and then Kashmir for 7 months.
Since arriving in Darfur, I have been working in the town of Kass in South Darfur, where I am responsible for overseeing MSF's therapeutic and supplementary feeding centres. Kass is a city about 60 kilometres south of the Jebel Marra. A large volcanic mountain, the Jebel Marra has traditionally been one of the richest farming areas, and therefore one of the most contested regions in Darfur. Many of the villages around Jebel Marra were attacked and burned last year and people had fled from town to town in search of safety and aid. As a result, Kass has nearly doubled in size with an estimated half of its approximately 90,000 residents being displaced people living in crowded camps, schools and empty buildings, or with friends and relatives.
The crowded living conditions and poor access to adequate food or clean drinking water combined with an overburdened health care system make Kass a high risk area for epidemics and malnutrition. When MSF arrived this summer, setting up a primary health clinic and feeding programmes targeting children under five were our first priorities.
Children under five are always the most vulnerable in a situation like this, so we have to keep a close eye on them. Generally, when a child gets malnourished, their immune system breaks down. They become much more susceptible to diarrhoea, respiratory infections, and skin problems.
When a child first arrives at the MSF clinic or feeding centre, we do a very rapid assessment of their nutritional state by seeing how big the circumference of their upper arm is using a special “MUAC” band. If we are concerned after the MUAC screening, we can make a more precise measurement of their nutritional status by taking their weight and height and comparing it to that of a normal child.
If a child is found to be acutely malnourished, he or she is immediately admitted into our therapeutic feeding centre (TFC) in order to receive carefully monitored feedings of special high-nutrition milk. The child will get medical treatment, including vitamins and antibiotics, to combat infections. Dehydration due to diarrhoea is also a common problem among malnourished children, so we will try to rehydrate them as quickly as possible.
Traditionally, a TFC is a 24-hour facility where both a caregiver and the child would be admitted so that the child can receive medically monitored feedings with special high-nutrition milk in order to build up their metabolisms. In Darfur, insecurity and the obligations of the mothers to their families who may be far away, makes it impossible for most caregivers to stay with us for 24 hours. So we have had to be more flexible. In Kass, MSF has set up a slightly different system of therapeutic feeding. Mothers come in from 8 in the morning until 4 in the afternoon and their child receives the milk we would normally administer over the course of 24 hours, in a shorter time. We also give the mothers special nutritional food packets when they go home each evening and provide additional nutritional support for mothers who may be having problems breastfeeding.
If a child is very sick, he might come in to the TFC every day for a week. Sometimes the children with edemas who actually might not look so bad to a lay person because they can have fat bellies and faces, can actually be very sick as the edemas are fluid and they might need to stay in the “daycare” TFC a bit longer. But, we try not to keep them for more than a week or ten days. If a child improves quickly and his or her appetite returns, we might discharge the child after just 4 or 5 days and put them in the “homecare” TFC programme where they will return once-a-week for special food and a medical check up to ensure that they are improving. A child might stay in the homecare TFC for a month or six weeks.
Once the child has regained enough weight and is really improving, we discharge them into the Supplementary Feeding Centre (SFC) programme. In the SFC programme, the caregiver and the child only have to come in once every two weeks. The child will receive a medical check up and the mother will get a ration of high nutrition “unimix” for her family that contains oil, corn and soy that she can make into a porridge that should help the child improve even more. Some children who are not acutely malnourished don't need the daily intensive feeding so might be admitted straight into our SFC. Finally, when the child reaches a weight that we consider normal, we discharge him or her, but of course tell the mother to come back right away if there are any problems.
Since MSF opened our feeding centers in Kass at the beginning of June, we've treated 1015 patients in the TFC and 3700 in the SFC. Right now we have about twenty children coming in every day for the daycare TFC and about 260 coming in on a weekly basis.
One of the patients in the TFC recently is an 18-month old child who was admitted in very poor condition. He had that skeletal look of a little old man, with a wizened face, big eyes and very, very thin arms and legs. The look is typical of mirasmic malnutrition and I was concerned that he could get very sick, very quickly. He might already have been sick for a couple of months and was getting worse with a bad cough, vomiting, and diarrhea. His mother told me that she had fled with her children from the Jebel Marra area and had arrived in Kass because they could not get enough food.
At first the boy did not want to drink any milk at all, but gradually he began to improve as the antibiotics slowed down his diarrhea and we were able to rehydrate him. He has a good appetite now and that is a good sign. His weight is a bit better and he looks a lot more like a little boy again. If we keep a close eye on him, he will continue to improve. Hopefully, there is nothing that will stop his mother from bringing him back each day and then in a week we can let him go home so that his mother will only have to bring him in every week.
Having a child in the daily TFC programme is a big burden on a mother. Many are here on their own with other children and family to take care of. But most know that their children are very sick so they still come in each day, and then in the evening go home to cook and look after all their other children. Many of the mothers even bring washing to the clinic, so we've prepared a place for them to do it so they can get their family laundry done while at the clinic. Unfortunately, there are still children who we can't keep in the programme.
The few weeks ago a nomad woman came into the feeding centre bringing a child who was acutely malnourished. I could tell right away that the child also had cerebral palsy or some other physical or mental handicap. The little girl was crying and very thin. Her mother told me she had diarrhoea and was coughing. The mother was very concerned for her daughter, but when we told her that she would have to stay with us in the TFC for at least a week if she wanted her child to get better, she told us that she could not come back even the next day. Her husband was waiting and they had to leave the next day on camelback to put their goats out to pasture.
But she did come back for a few hours the next morning and we did what we could. I gave her daughter a Vitamin A supplement to bolster her immune system as well as some anti-worm medicine as so many of the children here have them. We also vaccinated her against measles as malnourished children who get measles are more prone to die. We couldn't give her special milk that the child really needs, so we gave her two to three weeks of high-nutrition food for the child and urged her to come back as soon as she could. And just a few days ago, amazingly she did come back. It was good to see the child doing better and not crying or coughing. The diarrhoea had improved as well but we would still like a child this sick to have stayed with us longer. But we know we can't, so we can only give the mother more food for the child and her family as well as we know that her other children are probably in need too.
We want to find more of the people who are defaulting from our nutritional programme. We often hear that a mother is too sick herself or too old or has other children elsewhere and just can't make it to the TFC every day. So we have to be more flexible and give them food and medical treatment as best as we can, and hope they will come back. We also have a community health worker programme that does outreach in the community to find the mothers and children who are in need and work on strategies for helping them.
It is always nice to see kids getting better, especially when a child came into the feeding centre looking like a skeleton. You just really feel for the child's mother and it is so gratifying when the child comes back to life and starts looking like normal child again. At home it is a tragedy if a small child dies, but here it is very normal that a family has two or three children die from illness when they are young. And at a time like this when violence there isn't enough food, it is even worse.
It is good that MSF has been able to help many of the sickest children in Kass &#– all together we've helped nearly 5000 children in our feeding centres. People in the community also tell us that MSF is doing something valuable and that feels good. We are one of the only organisations that has been here since the beginning of June. In the MSF Primary Health Clinic that we opened this summer, we are doing over 200 consultations for children and adults each day. So I think MSF is offering the residents and displaced people in Kass a good professional level of health care and that is very satisfying. Now that our programme is stable and we have well-trained local staff, we are looking at strategies of how to get out to people who haven't been able to reach us.
If you ask people whether they want to go home, they all tell you that they will not go back until they feel safe again. We have heard of some people returning to their villages to check on their homes and properties, but found the situation still too insecure and most say they couldn't get back to their fields. They find everything they had was completely destroyed, and then come back to Kass saying it's not worth the risk.
At the moment the situation in Kass is quite peaceful, but that could change anytime, and there are still newly displaced people coming into the town. We are, thankfully, not seeing a head-on huge nutritional emergency – the food distributions and the medical care we have been able to provide have helped to stave this off for now &#– but that can change quickly. All of the displaced people are still completely dependent on aid and that makes the situation very precarious.
I am working with a very good team here and finding the work very satisfying. So as long as I get a break in the regional capital every six weeks or so to check out a Bollywood movie and have some ice cream, I am sure I will be just fine until I leave Darfur in February.