In Central African Republic babies have shown signs of post-traumatic stress disorder. Photograph: Stephanie Duvergé for ACF International
Treating malnutrition in humanitarian crises, such as conflict and natural disaster, is far more complex than simply curing disease and providing children with therapeutic foods. Often, post-traumatic stress disorder – common in extreme situations – hinders treatment and its success. In Bangui, in the Central African Republic (CAR), the number of children suffering from life-threatening malnutrition has tripled since the outbreak of violence in December 2013.
Each month, 180 patients are being seen in a ward that initially had just 49 beds available for malnourished children. For many weeks, two to three patients – and their caregivers – were sharing single beds, increasing the risk of cross-infection of illness and delaying recovery.
The cause of severe acute malnutrition runs far beyond economic hardship and lack of food. Many of the hundreds of thousands of people displaced by fighting have been directly exposed to death threats, witnessed the deaths of neighbours or family members, and lost nearly all of their belongings. They are often exhausted by the harsh living conditions in camps.
75% of over 1,000 case studies of the parents of malnourished children collected by Action Against Hunger between July 2013 and March 2014 presented symptoms of post-traumatic stress linked to their exposure to extreme violence. The stress prompted behavioural changes, flashbacks, fatigue, isolation, excessive irritability, and feelings of hopelessness and despair.
These experiences also provoked reactions that – while understandable, normal, and usually temporary – can be disabling enough to impact a mother’s ability to nurse and feed her child. Nurses leading pre- and post-natal sessions with women in the 12 health centres around Bangui have reported that some mothers become convinced they cannot produce milk, or fail to respond to their child’s needs, resulting in early weaning that can be fatal for babies in an already challenging environment. In extreme cases, some mothers have attempted suicide and infanticide.
Children, while too young to fully understand what they have witnessed, may develop physical symptoms such as continuous crying, refusing to eat and bed wetting. Even small babies can present signs of trauma, such as feeding and sleep disturbances, continuous crying, and poor interaction. Not recognising the signs, some parents don’t make the connection and severely scold their children. To combat this, malnourished children and their carers are receiving psychological and social support.
At the nutritional therapeutic ward of Bangui’s main pediatric hospital, Action Against Hunger’s nutritional, psychological and social teams offer free treatment for severely malnourished children from a specialised counselling team. Feeding times, medical monitoring and psychological and motor activities pace the daily routine.
When Dieumerci Tsongbele, a single parent to his six-year-old daughter Jessica, arrived at the hospital, she had been refusing food and was not interacting with others. When he joined a welcoming session led by psychological and social experts, Tsongbele and other parents learned about factors that exacerbate malnutrition, including trauma. The information evoked an emotional response from the father, who had witnessed people killed. While he managed to escape the violence, the experience had left him unable to sleep, irritable and hypervigilant. Overwhelmed by the situation, he admitted he had been less attentive to his daughter’s needs.
During the programme, Tsongbele and the other parents participated in various activities with their children ranging from toy making to baby massage, which aim to provide both parents and children with a safe space to recreate natural and vital bonds that are essential for human development. Play sessions help to limit the negative effects of malnutrition strengthen parent-child relationships. Malnutrition treatment is not simply about filling stomachs, but also restoring the desire to eat.
Names have been changed to protect identities.
Stephanie Duvergé is a Action Against Hunger psychologist in the Central African Republic. Follow @ACF_UK on Twitter.