The wilting flowers of Yusuf Batil

When I saw my colleague, Allison, pick up this refugee child I recognized instinctively why she could not resist stopping to check on her. For my part, it was a newly acquired instinct. A nutritionist does not go walkabout in a refugee camp for pleasure. I had come to recognize the children who were under treatment for malnutrition and to understand the efforts being made to nurse them back to good health. 

My colleague, Kevin, steps out of the food
distribution hut carrying a little boy who is too
weak to walk. The boy's mother is in tow,
 carrying his younger sister who is under
treatment for severe malnutrition. 
[Photo: UNHCR/T.Ongaro]

The idea of wilting flowers had come to me as I witnessed how flight had ravaged bodies of the children in Yusuf Batil camp.

I didn't see them on the roads,  pathways, playgrounds and front yards in the tented refugee settlement. Long periods deprived of calories had exhausted the poor little mites (and indeed their caregivers), and was slowly sapping the vigor and the very life out of them. They were too overcome by the ravages of malnutrition to be doing the same things as their fellow kids. 

This is how many refugees travelled, walking through hot, 
dry, dusty, snake- and scorpion-infested terrain. The people
in this photograph were lucky; they had a camel and a donkey
 so that some of the children got to ride, along with the men.
For the majority, it was a barefoot trek into the unknown.
[Photo: UNHCR/T.Lomuya]

9,000 kids at risk of severe malnutrition

Monday 6 August. I was chatting with Pillar, UNHCR's public health officer as we sheltered from the rain under a thatched open structure. To me, a non-expert, despite Pillar's reassurances, the situation of the kids sounded ominous. 

Their families were driven out of their homes and villages by bombs and bullets, and later by hunger. Forced to eat leaves and wild roots, and drink dirty water, they arrived in South Sudan exhausted. They had endured  terrifying journeys through heat and dust; journeys during which many abandoned children in their own desperate fight for survival.

As they fled, refugees used untreated water from open
sources, particularly man-made dams known as haffirs,
together with their precious livestock. Think how desperate
one must be draw this kind of water for domestic use. 
[Photo: UNHCR/T.Lomuya] 

In Yusuf Batil, the effects of grueling journeys, hiding in forests, mountains and caves without proper food and water had come to light. The refugees, particularly young children, were in a fragile state of health. Malnutrition rates among very young kids were soaring: 9,000 kids aged less than five years were at risk... 25% of the population! Pillar explained that the trauma of extreme physical exertion and prolonged lack of essential nutrients had debilitated their immune systems. 

"The children are extremely vulnerable to infection," she said. "Parasites, diarrhea, acute infection could be the most serious cause of malnutrition. Those who get infected deteriorate quickly..."

Every two weeks, supplementary food is distributed to
children aged less than five years through the blanket 
supplementary feeding programme (BSFP). 
The children are weighed, measured and screened for 
malnutrition and possible illness, and then treated medically
as needed. Under the BSFP, all "under fives" receive special 
food with the aim of improving or maintaining their
nutrition status as the case may be. The frequency of
check-ups enables health and nutrition experts
to monitor improvements of lack thereof in the
nutrition status of the children
[Photo: UNHCR/T.Ongaro]

As Pillar spoke, I scribbled furiously in my notebook, wishing I could videotape her, to capture the intensity and urgency in her voice and facial expression. She reassured me that all was not lost. She described some of the work that UNHCR and other partners were doing to ensure kids did not slip between the cracks.

Work like active case finding; going from tent to tent to find people, particularly children, who were unwell in order to give them proper medical care. Refugees frequently did not recognize symptoms of illness nor did they have the habit of seeking treatment for ailments. For malnourished children, they were tracing defaulters--children who failed to complete nutritional treatment--through home visits to ensure that caregivers, usually mothers, were not failing to feed and medicate recovering children properly.

The battle against disease in refugee camps is being fought at
community level where simple acts like washing hands with
soap before touching food, drinking oral rehydration
 salts and seeking medical help early makes the difference
between preventing and overcoming infection... and
getting seriously sick. [Photo: UNHCR/T.Ongaro]

Taking the fight against disease, particularly the debilitating effects of diarrhea to the front line, ORS (oral rehydration salts) points had been set up throughout Yusuf Batil. Trained volunteers distributed the ORS for free and demonstrated proper hygienic practices (frequently using clean treated water, clean jug, clean cup etc.). Sheikhs, the trusted community leaders, helped pass on messages about the dangers of diarrhea and the importance of visiting ORS points and seeking medical help.

Young women in on their way home from receiving blankets
and mosquito nets. [Photo: UNHCR/T.Ongaro]

Musings of a casual observer

Soon it stopped raining. Pillar and I parted. I started the first of many tours of Yusuf Batil.

I made my way around, meeting and greeting people. The place had an aura of a normal refugee settlement. It was hard to imagine there had been nothing here just two months ago. Yusuf Batil (named after a nearby village) was established in June 2012. In five weeks, the population of the refugee camp grew from 3,000 to 36,000!

General food distribution at Yusuf Batil.
[Photo: UNHCR/T.Ongaro]

The inhabitants of Yusuf Batil had been to hell and back. In this predictable and non-threatening environment where weapons fire was a thing of the past, a spirit of vitality has emerged. The refugee settlement is a hive of activity. The market thrives. 

Health centres had queues of waiting patients. Food distribution was a major event, with entire families coming out to participate. It was the same when they had mass distribution of blankets and mosquito nets, as a means to combating the increasing incidence of chest infections and malaria.

The market in Yusuf Batil shortly after a downpour of rain.
[Photo: UNHCR/T.Ongaro] 

The throng of people created an atmosphere of organized chaos.  The frantic efforts of UN staff, NGO workers and refugee leaders to make sure that things ran well and everyone got what they needed, were imperceptible to a casual observer. 

Young women at a tap stand in Yusuf Batil.
[Photo: UNHCR/T.Ongaro]

Water tap stands were always crowded with women and girls of all ages, each wearing colorful traditional clothing. I followed them home a few times to see how far they had to walk. They carried between 20 litres (kids) and 40 litres (adults) of water at a time on a stick balanced across their shoulders and moved at a trot. 

The London Olympics were on at the time. People were being cheered on, watched by millions throughout the world, winning medals for achieving similar feats. 

In Yusuf Batil this was just another mundane, if backbreaking, chore: women and girls carrying heavy weights three to five times a day over distances of up to 500 metres... everyday! 


Wandering around the refugee settlement, I saw kids amuse themselves like anywhere else in the world--perched on tree trunks, climbing and sliding down muddy anthills, playing in front of their family tents... 

What a smile!  

I also saw children engaged in child labor--not in the sense of being exploited by unscrupulous individuals, but no less arduous. They were playing their part in performing domestic chores, though working nonetheless.

Young girls, like women, did backbreaking work, carrying water and firewood for domestic several times a day. 

Often young girls--many could not have been a day over five years of age--took care of their of younger siblings including infants and helped prepare family meals.

In the early morning young boys and menfolk took the cows, sheep and goats out to graze, bringing them home at dusk.

I ruminated on what appeared to be an unfair division of labour. I felt strongly that the female gender got a raw deal.

And then one day, I had an "aha!" moment. The males performed only tasks that involved making money and protecting assets. They ran stalls in the market, herded livestock and carried goods on camels and donkeys. To indulge in domestic chores as distinct from moneymaking work would invite scorn; that was for womenfolk. This realization did not make make it seem any fairer... but I digress.

Up close: wilting flowers

They were emaciated and listless; hanging for dear life onto their mothers, concealed in the folds of their tobes (traditional untailored cloth that is the national dress of Sudan), or perhaps lying curled up in tents, the life slowly sapping out of them. 


Pillar had asked me to assist with the distribution of supplementary food to children. They needed volunteers.  I offered gladly looking forward to making a tangible contribution. I had been in Maban about one week.

The experience was an eye-opener. I finally got to the bottom of how my colleagues and their peers were battling the scourge of child malnutrition. I saw the process as a sieve by which sick and malnourished children were captured and nursed back to good health.

It was another rainy day in Yusuf Bati. When we arrived at the feeding centre they were were already offloading the special nutritional products for children. Outside large numbers of women and children had gathered. They had been mobilized through the sheikhs, trusted local leaders who assist with organizing activities on behalf of the people they represent. One sheikh's group after another came in turn. They had been told that all children aged five years or less had to be present.  

For many it was a lifeline, called "blanket" supplementary feeding. It covered all children in the age range of 5-59 months and provided extra food, over and above the regular rations distributed by the UN World Food Programme, given the kids' need for additional calories and nutrients. Pregnant and lactating mothers were also present. They would receive food so that they could pass precious nutrients on to their unborn and breastfeeding babies.

The team leader explained the procedure. Children would first be measured around the upper arm. That measurement would be recorded on a slip of paper. The child would then be weighed on a scale and measured for height. 

The combination of these measurements would be used to determine whether the child was malnourished, and if so whether moderately or severely. If severe, the child would be admitted to a special programme, as an in-patient or an out-patient depending on his or her state of health. All children would receive food for 15 days (until the next appointment) as well as Vitamin A tablets, and be vaccinated against measles on the first visit. In 15 days they would return, and the cycle would be repeated until the experts determined that the children's nutrition status had stabilized sufficiently for the blanket programme to end.


Things were proceeding well. Most of the kids were moderately malnourished. Among the few who were severely malnourished, nearly all were already enrolled in a therapeutic feeding programme which included weekly health checks. At the desk where I was helping, we found only two severely malnourished children who were not on the programme. One was a little girl. We rushed her to the emergency services. 

The other was a young boy. It was hard to tell his age. As the scene of this second case unfolded, everything Pillar had said to me fell into place...

Programmes for malnourished children were functioning. The challenge was to bring all the children in. The children were too weak to endure shocks. They must not fall sick. They must have adequate food. There were external factors to combat, like malaria and chest infections brought on by rainy season conditions. The children must be protected from these. Most of all, Pillar had said, the children need time. They need time for their bodies to absorb nutrients and regain strength.

It was gut-wrenching. Yet, because professional help was at hand, I felt a powerful sense of optimism and reassurance that with the efforts being made and the care being provided, the wilting flowers of Yusuf Batil would blossom.

One boy's story

My colleague, Kevin, emerged from the food distribution tent carrying a small boy. Later he said he had noticed the child was about to black out. A pediatrician-turned-epidemiologist, Kevin recognized the signs of distress and immediately swung into action.






The boy's mother followed closely behind carrying her daughter and the bag of food she had just received. Visibly she was expecting another child.

Inside the tent, the nutrition team was busy with the crowd of children and their mothers. So my other colleague, Brendon, a public health officer, took the boy's upper arm measurements.

The children's mother sat in a chair with her daughter on her laps. She seemed listless, even confused. Her daughter was on a treatment programme for severely malnourished children as an out-patient. This woman had more than her fair share of burdens: a sick daughter, pregnancy, domestic chores, and how her son.

The little boy clung to Kevin. He wrapped his arms around his neck. He could hardly open his eyes.

While we waited, Brendon examined the little girl. You did not have to be a health expert to see that this child could easily have lost her life to malnutrition.

The bag containing food, which the mother had carried, fell open. Out spilled the packets of nutrients that were intended for her and her children. The little girls reacted instantly. She reached out crying.

Brandon said it was a good thing (the crying). Severely malnourished children often refuse to eat. By then Kevin had finished the little boy's paperwork. We had to move on.

Missy was not amused. She howled in frustration.

One of the staff opened a sachet of plumpy nut and handed it over to Missy.

The transformation was instant... and heartwarming to watch.

Missy was, to say the least, oblivious to her surroundings and to her brother's emergency.

A vitamin A tablet for the lad, and one for the lass.

Measles vaccinations. The boy hardly flinched; the girl was riled.

A doctor rushed the trio to a waiting ambulance. 

Missy continued to relish her plumpy nut. 

What a huge relief to see them go, knowing that all three would be taken care of. 

A selection of photos

...from the BSFP -- blanket supplementary feeding programme -- in my definition, the sieve through which kids who were severely malnourished or sick were netted and treated.

Outside, families--mostly mothers--had braved the rain and were patiently waiting with the children.
They had been mobilized through the sheikhs. [Photo: UNHCR/T.Ongaro]

It was cold. You could tell from the way children huddled. Most kids own only the clothes they 
are wearing; no sweaters, no anoraks. [Photo: UNHCR/T.Ongaro]

Patience beyond compare. Most kids this age cannot keep still, nor not fuss with this degree of 
discomfort. Is it possible that these kids have a precocious knack of understanding the 
importance of going through this process?  [Photo: UNHCR/T.Ongaro]

In spite of the long waits and the evident discomfort, heartwarming smiles from mother and 
children alike. This has got to be the distinguishing feature of the people of Blue Nile state: 
despite the hardship they have endured, smiling and good cheers is second nature. 
[Photo: UNHCR/T.Ongaro]

Thoughtful expressions... all of them. Every time I look at refugees, I wonder about their story. 
How they came to be in South Sudan. I wonder whether their families are intact; who survived 
and who succumbed. I wonder, despite the outward appearance of wellness, what really 
goes on in their minds. [Photo: UNHCR/T.Ongaro]

This is what it looked like outside. Splashes of color as refugee women and girl children 
(and a few boys and men) waited their turn for their children to be weighed, measured, issued with 
food and vaccinated. [Photo: UNHCR/T.Ongaro]

Men also brought children to the feeding programme. We asked where the mothers were. 
Nine times out of ten the answer came: she was sick. It was important for women to come, 
especially if they were pregnant or breastfeeding, as they too got special food. 
[Photo: UNHCR/T.Ongaro]

These faces evoke concealed trauma. What is going on in those minds?
Memories of a harrowing journey? lost family members? a sense of isolation?
[Photo: UNHCR/T.Ongaro] 

The inevitable adorable imp! [Photo: UNHCR/T.Ongaro]