Thursday, March 6, 2014

Malnourished refugees facing death in Lebanon

[Originally posted at NOW]

Nearly 2,000 Syrian children under five are at risk of death from malnutrition, a number that UNICEF says could rise rapidly.

9-month-old Ibrahim al-Jarudi has been diagnosed with what the World Health Organization calls "severe acute malnutrition" (NOW/Alex Rowell)

QOB ELIAS, Lebanon: With his frail limbs, gaunt cheeks, and vacant look in his brown eyes, Ibrahim al-Jarudi doesn’t look like most other 9-month-olds. Sitting on the floor of the single room which he and his family of eight share in an open-air concrete building in the central Beqaa Valley, he makes little noise or motion as aid workers from the International Orthodox Christian Charities (IOCC) measure the circumference of his upper arm, which has withered down to the breadth of his wrist.

“Still SAM,” says one to her colleague, using the acronym for severe acute malnutrition, the most dangerous kind of malnourishment defined by the World Health Organization. For a while, Ibrahim was suffering only moderate acute malnutrition (MAM), the aid workers told NOW. But a recent fever and diarrhea onset has caused him to relapse to SAM, which the WHO estimates would put his chances of dying at between 30% and 50% if left untreated.

Ibrahim’s is a relatively new but fast-growing condition among Syrian refugee infants in Lebanon, nearly 2,000 of whom under the age of five are now “at risk of dying” from malnutrition, according to a UNICEF statement last week. A handful have, in fact, already died – perhaps “four or five,” NOW was told by Linda Shaker-Berbari, Lebanon Country Representative at IOCC, which is among UNICEF’s leading partners in tackling the issue. Adding the SAM cases to the more than 8,000 diagnosed with MAM, there are thus over 10,000 acutely malnourished Syrian infants in the country (around 6% of the under-five refugee population), with the prevalence of SAM almost doubling since 2012, according to data sent to NOW by UNICEF. Unprecedented as this is, owing to “aggravating factors” – not least the continuing influx of refugees into Lebanon – UNICEF warns the situation still has the potential to further “deteriorate rapidly.”

As a result, UNICEF and its partners are redoubling their efforts to combat the threat, by increased detection, treatment, and awareness of its causes. At Qob Elias’ public clinic Tuesday, NOW watched as IOCC workers screened some of the dozens of Syrian children brought in by anxious mothers living nearby (often in squalid, makeshift campsites). As well as the upper arm circumference measurement, which detects muscle “wasting,” they pressed the children’s feet with their thumbs to check for oedema, a form of swelling caused by mineral and protein deficiency.

Some children were fine. Others looked fine, but on inspection turned out to have MAM (one of the dangers is parents often don’t realize their children are malnourished until they’re professionally screened). Others, however, were obviously undernourished: their skeletal arms no thicker than broomsticks; their ankles plump with retained fluid.

Immediately afterward, the IOCC workers then measured the children’s height and weight to detect possible “stunting,” a lag in physical growth that, if not quickly addressed, can be irreversible. While not in itself fatal, stunting is still a “serious” form of malnourishment, Shaker-Berbari told NOW. It is also much more prevalent than acute malnutrition, afflicting 17% of refugees under five as of November 2013 (up from 12% in September 2012), according to data sent by UNICEF.

Once diagnosed with acute malnutrition, the children are prescribed a course of intensely nutritious dietary supplements, known as ready-to-use therapeutic foods (RUTFs), which come in the form of a kind of paste that can be eaten straight out the sachet. These are provided free of charge, paid for by UNICEF and UNHCR. The children’s parents are then asked to return once a week for a check-up, during which the full screening process is repeated, and the treatment amended if necessary.

Supplements by themselves, however, cannot fully solve the problem. As with Ibrahim, illness such as diarrhea can quickly turn a MAM case into a SAM one. And illnesses are easily picked up in the harsh environment of a tent settlement or overcrowded building, where “water and sanitary conditions, shelter conditions, hygiene, and access to healthcare” are gravely inadequate, said Shaker-Berbari.

Yet, aside from the immediate factor of illness, perhaps the single most important underlying cause of malnutrition is a lack of breastfeeding, according to Shaker-Berbari. “Breastfeeding is lifesaving,” she tells NOW, lamenting the “very, very dangerous” practice of refugee mothers using infant formula as a substitute. The problem, IOCC workers in the clinic explained to NOW, is not merely that breast milk is nutritionally superior – particularly in the days immediately after birth, when it contains vital antibodies – but that, without access to clean water and sterilized appliances, refugees using infant formula are recklessly (if unknowingly) putting their children’s health at potentially grave risk.

Indeed, it may well have been for this reason that Ibrahim relapsed to SAM. As his father, Muhammad, passed traditional ceramic cups of coffee around the room, one IOCC worker politely inquired about a milk bottle plainly visible on a nearby table. With some embarrassment, Ibrahim’s mother confessed that though she had started breastfeeding him, she had continued to supplement this with formula. “We’ve told you before, this is the biggest mistake you can make,” said the IOCC worker, urging her to attend an upcoming breastfeeding awareness session at the clinic.

Of course, fueling both the illness and feeding problems is the simple poverty that is also an underlying cause of malnutrition, as well as the root of so much of refugees’ hardship in general. Muhammad insists that the rest of the family have enough food to get by for now, even if they can only afford to eat meat once a week. But this too could soon take a turn for the worse, as the mounting number of adult refugees combines with Lebanon’s declining economy.

“It’s been three months now that I haven’t been able to find work,” Muhammad says. “This room costs $250 a month, and I haven’t been able to pay the landlord for two months.”

“I’ve tried everything, even applying for a visa to go to Germany, but nothing is working out. What am I to do now?”

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