Overcrowding is the norm at the children's nutrition and therapeutic feeding centre at Matany Referral Hospital in Karamoja, northeastern Uganda. The region has the highest malnutrition rate in the country.

"The overcrowding raises the risk of cross-infections from other wards; just today [11 September] we had 43 admissions while the ward has only eight beds," James Lemukol, the hospital's medical superintendent, told IRIN.

"Some of the desperate cases we handle in this ward involve children, some of them hardly 10 years old, taking care of their malnourished younger brother or sister because their parents cannot do this task as they have more children they have to fend for at home," Lemukol added.

Due to the overcrowding, Lemukol said, some of the patients share beds while others sleep on the floor, making hypothermia a major killer of the malnourished children.

The situation at the Matany hospital reflects the desperate health picture across the vast Karamoja region, inhabited by an estimated one million people, most of whom are pastoralists.

Humanitarian challenges

According to the UN Children’s Fund (UNICEF), Karamoja represents a developmental and humanitarian challenge to Uganda's stability and poverty eradication efforts. "Mortality and malnutrition levels routinely surpass recognised crisis thresholds," a UNICEF briefing note indicates. "Levels of education, literacy and access to information are extremely low, as is access to potable water and sanitation facilities. Cultural and climatic factors as well as endemic conflict combine to create cyclic humanitarian crises of a disastrous scale and complexity."

The reason, UNICEF says, is due to a mixture of competing livelihoods, a breakdown of traditional values and social behaviour control systems, a history of marginalisation and high levels of small arms availability. These factors have created a state of continuous violence characterised by inter-communal and cross-border raiding.

"Pressure for disarmament grows in parallel to the increasing armed competition for land, pasture, livestock and water," UNICEF says. "The population remains vulnerable to attack and there are regular casualties, disruption to the lives of children and displacement between communities."

After unusually high rainfall in the past few months, most of the usually semi-arid Karamoja region was deceptively green between August and September, with sunflower, millet and maize stalks competing in the fields.

However, food insecurity continues to dog the region, with an estimated two-thirds of the population depending on food aid.

"Crop harvests this year have been affected by the heavy rains," said Moses Chuna Kapolon, the administrative officer of Moroto, one of the five districts in the region. "Sustaining food security in this month [September] is not guaranteed."

Cyclic drought in the region has aggravated the situation, affecting both crops and livestock, causing food insecurity and severe malnutrition, especially in infants and children younger than five. Indeed, the child survival rate in Karamoja is among the worst in the world, according to UN agencies.

Due to its semi-arid nature, villages are far apart and families seeking treatment for their malnourished children have to trek many kilometres to reach hospitals or food distribution points and the therapeutic feeding centres and nutrition services in a few of the region's health facilities.

In Kaabong district, a project to reduce morbidity and mortality among children started in July, with the support of UNICEF and the UN World Food Programme (WFP), and is being implemented by Médicos Sin Fronteras (MSF-Spain).

Tina Varga, the MSF project coordinator, told IRIN the project was set up in response to a WFP nutrition survey in March-April that showed the district's nutritional situation deteriorating.

She said MSF had since opened stabilisation centres and ambulatory therapeutic feeding centres in six locations across the district.

"Children identified as eligible for the programme receive a medical screening and treatment, and then receive therapeutic food, supplied by UNICEF." Varga said. "Those detected to have medical complications requiring hospitalisation are referred to Kaabong hospital."

UNICEF and WFP also support the provision of food and therapeutic feeding centres in other parts of Karamoja, often using local service providers – governmental and non-governmental, such as MSF, OXFAM, district health services and the Comboni Mission, which runs Matany hospitals.

Childhood malnutrition

According to the Uganda Demographic and Health Survey for 2006, poor infant and young child feeding practices were responsible for high levels of childhood malnutrition in the country, with 38 percent of children under five being stunted and 16 percent underweight.

The survey showed that Karamoja had the highest rate of stunting, at 54 percent, compared with 50 percent for the southwest; 40 percent in the northern region; 36 percent in the eastern and 30 percent in central Uganda.

According to Jeremy England, eastern region manager for UNICEF, the indicators that point to the nature of Karamoja's "chronic emergency" include: high rates of global acute malnutrition (GAM) and mortality, the number of security incidents - roughly 30 a week - as well as 500 deaths due to trauma or gun violence every year.

England said UNICEF’s budget for Karamoja region for 2007 exceeds US$7 million so far, adding that the region required substantial development investment to move from a crisis phase to peace and development.

"It’s been incredibly difficult to mobilise in Karamoja but after about two years, I’m beginning to feel that UNICEF and other UN agencies are putting together a package that will have a lasting impact," he said.

He added: "There are willing and competent partners who need support and technical guidance and we have to work through these partners because they are the ones trusted by the people.”

England said there was a need for improved support for district health services in terms of equipment, outreach programmes, communication, water, electrification and sanitation.

"This package starts to come together if all these aspects are functional," England said.