"The numbers [of children receiving Plumpy Nut] should start dropping off by now, but they have not," said UN Children's Fund nutrition officer Jean Luboya in UNICEF's Abéché office, speaking about the nutrient-packed peanut paste given to severely malnourished children.
Of 853 children in Abéché surveyed in June 2009 by the NGO Action Contre la Faim, 22.7 percent of under-five children were acutely malnourished and 6 percent had severe acute malnutrition, according to World Health Organization norms.
During the June to September rainy season when farmers head to the fields in the east to cultivate, markets are more barren and nutrition centres and the regional hospital's malnutrition ward distribute about six metric tonnes of Plumpy Nut a month. Numbers typically decrease after the harvest to 3.5 mt a month from January to April, according to the Abéché UNICEF office.
But in 2009 thus far, Plumpy Nut distribution in Abéché has not decreased much from its peak levels in August said nutrition manager Luboya. Population growth, price increases and a shortened growing season are all to blame for high malnutrition levels, Luboya told IRIN.
Because of late and sporadic rains during this year's growing season, the government has estimated a 34-percent drop nationwide in cereal production from last year's 1.7 million mt. The National Food Security Office (ONASA) has reported 9,000 mt of cereal reserve, which is one-quarter of its goal.
An October Ministry of Agriculture note on the 2009/2010 harvest noted: "Resupplying this reserve could prove to be expensive and difficult to execute, given the relatively higher market costs [of cereal]." The note predicted higher food prices in early 2010 than 2009, making it harder for pastoral and urban groups to get food.
Since the arrival of Sudanese refugees in Chad's eastern region in late 2003 and the spread of aid and NGO agencies in the hub town of Abéché, the population has multiplied from 50,000 to 300,000 in 2009, based on the most recent government census projections.
"Services intended for fewer numbers are now being stretched to cover needs many times greater," said UNICEF's Luboya. "Sanitation services were not created to handle so many. Already understaffed hospitals are forced to handle an even higher volume of patients. Poor access to water has worsened overall nutrition."
A dozen UN agencies now work in Abéché where only one had in 2003; dozens of non-profits and more than 1,000 civil and military members of the UN peacekeeping MINURCAT are also based in Abéché.
This has increased housing and food costs to levels most locals cannot afford, according to the French research and training group, Urgence Réhabilitation Développement (Emergency Rehabilitation Development).
Since the beginning of the year the regional hospital in Abéché has treated 419 children for severe acute malnutrition. The hospital continues to admit 60 new children every month, which is higher than normal for this period of the year, according to UNICEF.
Two-year old Fatouma Dagache had already been sick for two months in her village Biltine, 95km north of Abéché, when she was accidentally hit by rebel fire in October, her mother Issein Tahir Atir, 25, told IRIN.
UNICEF's Luboya told IRIN there has been no effort to identify residents in Abéché who were displaced from fighting near the border with Sudan. "They disappear when they come here to the city. They may not want to be identified as displaced. Most just want to get on with their life. They do not receive any assistance from agencies, but are most likely more destitute than locals and at higher risk for malnutrition."
People who flee to cities because of conflicts or natural disasters tend to become invisible to the authorities and organizations that can help them, according to a 2008 study by the US-based Tufts University and the Geneva-based International Displacement Monitoring Centre of urban displaced.
Displaced or not, the urban malnourished are often overlooked, said UNICEF's Luboya. "People think that because urban areas have more amenities that hunger is a structural problem here, that the real problem is poverty."
He said the poor are hit harder by price increases, conflict, security problems and rural exodus due to the fighting. "Children die from hunger - even in cities."