Guardian.co.uk
Annie Kelly
Hellen Apale knows how important it is that her children get a good diet. She knows that at eight months pregnant, she needs to be eating well and eating regularly for the health of her unborn baby. The problem is she has no food.
"We had a really bad harvest, there was a drought which came early last year and it has affected everyone," she says, gesturing to the scrubby field outside her home, where cassava plants wilt in the brown cracked earth. "It's not how it used to be when we could easily grow enough to feed everybody. Children are falling sick easily, sometimes we can only feed the family one meal a day."
As a village health team member, trained by the African Medical and Research Foundation (Amref), Apale knows all about the dangers of malnutrition. At the same time she is hoping and praying the rains that have finally come to Katine will be hard and long lasting, she is fretting about the risk of malaria.
"I know my children are malnourished and I know this means they could get malaria easier than if they were strong," she says. "Even the adults are weak now, so we're worried that disease will come and we won't be able to afford medicines or treatment."
Apale, her husband Richard and her six children live in a remote hamlet deep in the heart of the Katine sub-county in north-east Uganda, where Amref is implementing a development programme, funded by Guardian readers and Barclays. The family survives on crops and vegetables grown on five acres of land around their house. Bad rains last year mean that production was down.
The Apale family's food supplies are now so low that they have begun rationing meals. Apale and her husband have only been eating once a day and their children have all gone without an evening meal for the past week.
"I know that if you don't feed your children enough then they can get anaemic and I'm worried not only for the health of my unborn baby but also for myself because childbirth is hard and if I'm not strong enough then it's dangerous and recovery could be difficult," she says.
Apale has to walk more than 6km to reach the Tiriri health centre, the nearest place she can access neo-natal services. The morning surgery is packed with expectant mothers and small babies all being seen by one midwife, Jennifer Amyago.
Amyago trained at the Ngora School of Nursing and worked in north Uganda a decade ago when the Lord's Resistance Army (LRA) rebels were burning clinics and displacing thousands of young families.
She says the levels of malnutrition in Katine and the surrounding area are low compared with the starvation experienced in the north during the insurgency and the food shortages currently crippling the Teso region's Karamoja area.
But she is worried. Over the past few months she has noticed a spike in the number of babies being born dangerously underweight across Katine, a sign, she says that mothers aren't getting the nutrition they need.
"We're getting more babies under 2.5kg, more premature births and I'd say it was a growing problem," she says. "The numbers of recently born babies who are coming back to the clinic showing early signs of malnourishment are also growing. When mothers can't breastfeed we tell them to buy milk formula but nobody can afford it, even though in these cases it's often the best way of getting the proteins and calcium these children need. But if milk formula now costs Shs 20,000 (around $9) then what can they do?"
Poor nutrition undermines many health interventions in rural areas like Katine. An estimated 35% of child mortality across the world is attributable to poor nutrition. In rural areas, lack of proper nutrition can lead to common diseases such as marasmus, leading to chronic weight loss, and kwashiorkor, resulting from a lack of protein which leads to dangerous swelling of the feet and legs.
Poor nutrition also has serious knock-on effects on wider efforts to improve education and livelihoods across the sub-county.
"Malnutrition can be a serious barrier to the success of health interventions," says Susan Wandera, deputy director at Amref Uganda. "Good health depends on good nutrition and a lack of food will leave people more vulnerable to disease, make treatment more difficult and put more strain on an already overstretched health system. It also affects productivity and compromises education."
Wandera says up to 90% of children in Katine spend the whole day at school without having anything to eat.
"Not only will this impact on their ability to concentrate and learn in the classroom, but for children who are growing this means they run a real risk of becoming endemically malnourished," says Wandera. "This will affect their physical and mental development, especially if they are facing long-term food shortages in the home. This poses a real challenge to any education or health initiatives we're trying to run."
The problems the Apale family are facing in Katine have been exacerbated not just by drought, but rising food prices. Even though the price of staple foods such as maize and beans have decreased from record highs last year, they are still far higher than pre-2008.
This means that if the harvests fail as they did last year, the family not only doesn't have any crops to sell, they don't have enough money to buy sufficient staple foods. Any assets they do have, such as goats or cattle, decrease in value as a consequence. The situation is made worse by the fact their livestock are in increasingly poor health because the family can't afford to feed them properly.
Wandera says food production is lower than normal because of last year's poor harvests and accepts many families in Katine will be facing food shortages. However, she says in general eastern Uganda is quite robust in terms of food security.
"The kind of food grown in Katine and across eastern Uganda, like cassava and groundnuts, can be dried and kept for longer periods. These areas are also less likely to suffer from long-term droughts," she says. "Now the rains have come to Katine I hope this won't be as big a problem as it could be."
But as the G20 nations meet today to discuss how to tackle an increasingly catastrophic global financial downturn, what is worrying Amref and other development agencies is what is to come.
Save the Children estimates that in 2008, 8.7 million children became malnourished as a result of high food prices, with the economic crisis set to push these figures higher.
The World Bank has predicted that child deaths in developing countries could be 200,000 to 400,000 per year higher on average between 2009 and 2015 than they would have been in the absence of the economic and financial crisis.
"Food prices are going to have a big effect on malnutrition, especially if and when aid budgets start being cut," says Wandera. "If you look at Uganda, which has a health budget that is 50% funded by international donors, we're likely to see more people being pushed into poverty and unable to buy sufficient food or access health services. At the same time you're going to have less money going into health budgets to cope with the extra burden that more malnutrition will bring. It's a recipe for disaster."
Hellen Apale says her community needs immediate support in the form of food supplements and improved high-yield seeds and cuttings if they want to stave off malnourishment and bigger health problems.
"The government always say they will help, but help never comes," she says. "They should be the last people we turn to. We are very happy with the new demonstration farms set up by Amref, but they only help a small number of people. If possible everyone should be given cassava cuttings or improved seeds to help us grow enough to feed our families."
While Amref doesn't provide food supplements - arguing it creates a culture of dependancy and is unsustainable - it does say its livelihoods programme will help families like the Apales in the long-term.
"What we're trying to do is put in place some sustainable training and skills to help farmers increase productivity," says Wandera. "It's only through helping improve livelihoods that that communities will be able to deal with what is ahead."
In the meantime Apale is hoping the rains last long and hard and that they will be able to grow enough to see them throughout the year.
"It's hard but lots of people are in the same position," she says. "I just hope by the time the baby is born things will have got a little better because as a mother it is hard to see your children go hungry."
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