Afghanistan Humanitarian Bulletin Issue 54 | 01 – 31 July 2016

HIGHLIGHTS

• Malnutrition affects 2.7 million people including a million children under the age of five.
Only 35 per cent of children with severe acute malnutrition are being reached and of those, only 25 per cent are actually cured.

• Despite access constraints, conflict and displacement, Medair delivers critical nutrition support in the South

• More than 5,000 people Afghans are returning from Pakistan per day

• Highest amount of civilian casualties for the first six months of 2016 ever recorded in Afghanistan, one-third of them children- UNAMA reports

Malnutrition: the silent killer in Afghanistan

The number of children killed by conflict in 2015 represents less than 1 per cent of the estimated number of children dying due to malnutrition in one year in Afghanistan.

Afghanistan’s children living in the shadow of armed conflict face a real and present danger. Between January and June this year, 388 children lost their lives primarily resulting from ground engagements between anti-government elements and Afghan forces. Another 100,000 children fled from their homes as their parents sought to get them to safety. While the daily battles and skirmishes have a recognisable impact on the lives of children, the unrelenting conflict overshadowing the country for the last decades has considerably impeded development progress. The result is an altogether more dangerous environment for children where, in contrast to the conflict, it is the unseen dangers that are exacting loss of life with implacable ferocity.

Afghanistan has the second highest rate of under-five mortality in the world. For every one thousand babies born, fifty-five will die before the age of five. Eighty-two per cent of these deaths will occur even before the child’s first birthday. Most of these children will die from easily preventable or treatable conditions such as diarrhoea or pneumonia. In Afghanistan these common conditions are made much more dangerous due to the additional presence of malnutrition. An undernourished child is not only weak and less able to withstand an attack of illness, the illness itself also makes the child much more susceptible to becoming malnourished. As such, while rarely cited as a leading cause, malnutrition is the hidden contributing factor in about 45 per cent of all child deaths.

The Afghanistan Nutrition Cluster estimates 2.7 million people are affected by malnutrition including one million children under five with an acute state of malnutrition in need of treatment. In contrast to the palpable impact of violence, the ordinarily hidden nature of malnutrition severely frustrates efforts to confront this considerable threat to young life. Lack of awareness about malnutrition has been identified as one of the top barriers preventing children from accessing treatment.
Rural mothers in Afghanistan lack adequate knowledge about malnutrition and so can rarely identify this as a cause or contributing factor to their child’s ill health. When their child gets a bout of diarrhoea they are unable to understand how a poor or inadequate diet has made them more susceptible to infection through lowered immunity or likewise how the diarrhoea itself prevents absorption of foods, and causes loss of appetite resulting in a vicious cycle of undernutrition and infection.

This lack of knowledge and understanding makes the community mobilisation component of the customary approach to treating malnutrition so important. Once a child becomes malnourished they face a roughly three times higher risk of dying from common communicable diseases than if they were well-nourished. Once they deteriorate to being severely malnourished, typically thirty to fifty per cent of these children die. Working with communities to identify malnutrition and to actively screen and monitor all young children regularly is therefore critical to ensure malnutrition can be identified early and treated immediately. This high level of coverage achieved for treatment programmes through engagement with communities is crucial to the substantial reduction in fatalities that can be achieved through effective Community or Integrated Management of Acute Malnutrition (CMAM/IMAM) programming.

Afghanistan’s IMAM programmes, however, have distinctively low coverage. UNICEF analysis suggests only 38 per cent of health facilities are providing nutrition services. This figure is all the more concerning given that health facilities only cover a generously estimated 60 per cent of the population. What is more, health facility based treatment does little to meet the needs of the children noted above, whose parents are mainly unaware of their condition until they deteriorate to an almost irreparable stage. The community outreach and active case finding is therefore critical to have any traction in combatting the malnutrition crisis faced by Afghanistan’s children.

Enhancing community level programming will be impossible as long as the current approach and services intended to treat malnutrition remain critically under resourced.

Working from the 2001 baseline of a devastated health system and some of the worst health statistics in the world, Afghanistan’s approach to delivering nationwide healthcare through contracting out its provision of services to non-governmental organisations under a Basic Package of Health Services (BPHS) has documented a number of successes.

However, in its current state, the international donor dependent health system is facing multiple challenges in terms of ensuring quality and reducing inequities in access resulting from various internal bottlenecks related to human resources, information management, health system financing and governance as well as supply chain issues.

The persistent poor health indicators for the country and the challenges within the system will be genuinely impossible to overcome while the average per capita budget for provision of BPHS remains at approximately US$5.

In terms of financing a response to malnutrition the under resourcing of BPHS has significant implications. IMAM was officially included in the BPHS in 2010, however this nutrition component has been particularly under-staffed and under resourced. The majority of health facilities do not offer nutrition services and those that do lack dedicated nutrition capacity. Only 50 per cent of facilities surveyed by the Afghanistan National Nutrition Cluster reported their staff (medical doctors, midwifes, nurses) had received training on nutrition in the previous year. With such poor coverage and quality of services it is hardly surprising only 35 per cent of children with severe acute malnutrition are being reached and of those only 25 per cent are actually cured.

Partial attempts to enhance treatment services which focus only on the most severely malnourished children are short sighted. As demonstrated through a recent assessment in Herat, the lack of treatment services for moderately malnourished children only resulted in high numbers of severe cases in the province as the children’s health inevitably worsened. Likewise, ignoring high rates of malnutrition among pregnant mothers not only impacts a woman’s chances of surviving pregnancy but perpetuates an intergenerational cycle of malnutrition. In Afghanistan, this cycle is accentuated by high rates of pregnancy among adolescent girls who themselves often suffer stunted growth due to poor nutrition.

As such they are highly likely to have low-birth-weight babies, significantly contributing to infant mortality and severe short- and long-term adverse health consequences and markedly increasing the chance of malnutrition and irreversible cumulative growth and development deficits.
Malnutrition of pregnant mothers and their young babies can affect the normal brain development of the child impacting their cognitive, motor, and socioemotional skills throughout childhood. The restricted development of these skills puts them at a critical disadvantage as they grow into adults, inhibiting their ability to learn and achieve results in school or find skilled employment. Consequently the ability to provide for and care for their own children is also reduced, thus contributing to the intergenerational transmission of poverty and malnutrition.

The humanitarian community recognizes that alone emergency curative interventions to treat malnutrition will be redundant. Malnutrition is a multidimensional issue with several underlying determinants and influences far from simply consuming sufficient food. Equally important is the existence of a healthy environment, access to safe water and sanitation facilities, provision of health care and shelter, the ability to influence caregiver behaviours and importantly the status a woman has and the choices she is free to make for her health and her child’s health in the society in which she lives. Ultimately peace and security and an enabling environment for all of the above is paramount.
Unfortunately as the conflict shows no sign of abating and the shifting security environment further hinders access to health and nutrition services increasing numbers of children are at risk. While parents seek to protect their children by fleeing from the danger of active conflict, the situation they find themselves in when displaced can be just as life threatening for their children. In the past months, alarming health indicators have been reported among displaced populations, exhibiting extreme vulnerabilities having been displaced repeatedly or for prolonged periods. Food insecurity, limited access to basic services, particularly health care and adequate water and sanitation, contribute to critical circumstances in which children’s risk to infection and disease is exacerbated.
Assessments of displaced populations, both IDPs and refugees, published in the last months have identified emergency levels of severe acute malnutrition among displaced children.

In July the Nutrition cluster revised upwards their financial request under the 2016 Afghanistan Humanitarian Response Plan to $69 million for urgent interventions to treat 285,000 children and 136,000 mothers as well as enhance prevention measures through simple approaches such as promotion of Infant and Young Child Feeding and micronutrient supplementation. The cluster has so far received $56 million however the targets for treatment are well below the actual needs in the country. For the third year running the Afghanistan Common Humanitarian Fund is allocating resources specifically for emergency nutrition projects. The focus of the 2016 allocation will provide treatment for displaced children, ensure complimentary treatment for moderately malnourished children and pregnant women alongside the SAM programmes, and critically enhance access to Therapeutic Feeding Units for the increasing numbers of children that have deteriorated to such critical levels they require hospitalisation.