Combating Childhood Malnutrition in Somalia

For almost 25 years now, Somalia has been embroiled in a devastating civil war. In 2014 alone, more than 100,000 civilians were “killed, injured or displaced by armed conflict and generalized violence” (Amnesty International, 2014/15, p. 8). This fighting, along with frequent droughts and floods, has overwhelmed the coping abilities of millions of Somalis, “resulting in inadequate access to and availability of food” (p. 4). It should come as no surprise, then, that Somalia has one of the world’s highest childhood malnutrition rates, with one in eight children under five suffering from acute malnutrition (10 facts, 2015) and tens of thousands of others suffering from severe malnutrition (“Nutrition,” n.d.).

Malnutrition “puts children at greater risk of dying from common infections, increases the frequency and severity of such infections, and contributes to delayed recovery” (Undernutrition contributes, 2015). Almost half of all deaths of children under five are attributable to malnutrition (Undernutrition contributes, 2015). Malnourished children who do not die from malnutrition suffer in other ways. Victora et al. (2008) found that childhood malnutrition leads to “leads to permanent impairment,” including “shorter adult height, less schooling, reduced economic productivity, and—for women—lower offspring birthweight,” and possibly mental illness (p. 340).

This paper (1) examines the risk factors of childhood malnutrition in Somalia, (2) explores childhood malnutrition in Somalia in terms of human rights and social justice, and (3) outlines possible solution,

Risk Factors

Kinyoki, Berkley, Moloney, Kandala, and Noor (2015) argue that diarrhea and drought are the two biggest risk factors for childhood malnutrition in Somalia (p. 3125). They found the relationship between malnutrition and diarrhea to be bidirectional, as diarrhea “may result in malnutrition because of reduced intake of nutrients, malabsorption, fecal nutrient losses and the effects of inflammatory response,” while malnutrition may also lead to “loss of immunity which leads to frequent enteric infection among children” (p. 3131). Drought is another “key driver” of malnutrition, as it reduces agricultural output and can lead to famine (pp. 3125, 3131-3132).

Another risk factor for childhood malnutrition is the limitations that American banks often place on Somali-American money transfer operators (MTOs). US law requires banks “to assist federal government agencies in detecting and preventing money laundering and terrorism,” and if these banks “fail to do so, the US Treasury Department’s Financial Crimes Enforcement Network (FinCEN) and other regulatory agencies can impose multibillion-dollar monetary penalties and/or terminate the institutions’ operating licenses” (Orozco & Yansura, 2014, p. 19). Since the “war on terrorism” began in 2001, US banks have concluded that remittances to Somalia “are fraught with risk” (p. 21), believing that they might end up in the hands of al-Shabaab or other Islamist groups, and consequently, many banks “have unceremoniously closed the accounts” of Somali-American MTOs “without providing any specific reasons or justifications” (p. 4).

The closure of these MTOs has limited the amount of remittances entering Somalia, making it more difficult for Somali families to stay fed. Orozco and Yansura (2014) note that every year, Somali-Americans use MTOs to send approximately $215 million to family members in Somalia, a significant sum of money that nearly totals the amount of development and humanitarian aid the US government gives Somalia (p. 4). During especially rough times such as the 2011 drought, “the generosity of the Somali diaspora [has] played a vital role in helping Somali families survive” (p. 4).

Human Rights and Social Justice

Being properly nourished is a basic human right. As Article 25 of the Universal Declaration of Human Rights declares, “Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services” (United Nations, 1948).

The obligation of foreigners to fight Somalia’s child malnutrition problem can be justified on Rawlsian grounds. John Rawls (1999) believed that humans are rational, self-interested beings who consequently favor principles of justice that favor themselves. The wealthy, for example, “advance the principle that various taxes for welfare measures be counted unjust,” while the poor “propose the contrary principle” (p. 17). Because of this, Rawls argued that the best way to choose principles of justice is to pick them behind a “veil of ignorance.” In other words, he imagined a hypothetical situation in which “no one knows his place in society, his class position or social status, nor does any one know his fortune in the distribution of natural assets and abilities, his intelligence, strength, and the like” (p. 11). Rawls believed that people behind the veil would conclude that, although “the distribution of wealth and income need not be equal, it must be to everyone’s advantage” (p. 53). So, for example, if the average middle class American believed they might be born a peasant in a developing country, they would advocate a system in which a meaningful portion of the developed world’s surplus wealth were shared with the developing world. Based on this principle, it follows that those in the developed world have an obligation to fight childhood malnutrition in Somalia.

Solutions

Social workers should take the following steps to combat Somalia’s childhood malnutrition problem: (1) advocate for peace, (2) better use climate indicators, (3) advocate for MTO reform, and (4) improve nutrition and health services.

1.0) Advocate for Peace
Ostrach and Singer (2012) provide a number of case studies, including the first few years of the Somali Civil War, showing that war is an almost unimaginably destructive force, “causing physical and emotional trauma in populations, destroying health care systems and social infrastructures, despoiling the environment, intentionally or unintentionally causing or exacerbating food insecurity and malnutrition, creating refugee populations, and spreading infections” (p. 257). Given this, social workers wanting to alleviate childhood malnutrition in Somalia must be vocal advocates for peace.

Many in the West believe that al-Shabaab and other Islamic extremist groups must be countered with force, but even though force might sometimes be justified, social workers must educate the public about the devastating consequences of war and look for and advocate nonviolent solutions. The International Crisis Group (2014) argues that the ideology espoused by al-Shabaab is deeply entrenched in large areas of Somalia and that the group has shown a “proven ability to adapt, militarily and politically” (p. 1). Given all this, the Crisis Group concludes that the Somali people can be best helped, not by more military actions, but by “national and local reconciliation processes at all levels of Somali society,” as well as making the government less corrupt and more democratic (pp. 1-2).

2.0) Better Use Climate Indicators
Although nothing can be done to stop drought from occurring, Kinyoki et al. (2015) argue that relief organizations can make better use of climate indicators, quantifying them “at reasonable temporal and spatial resolutions, to forecast possible risks of malnutrition to support effective planning” (p. 3132). By taking this approach, relief organizations would be able to more quickly “respond to emerging nutritional threats in the country” (p. 3132).

3.0) Advocate for MTO Reform
Orozco and Yansura (2014) offer several recommendations for increasing the number of remittances going into Somalia. First, they write that financial institutions should make more of an effort “to evaluate Somali-American MTOs applications on a case-by-case basis” instead of making blanking judgments about all Somali-American MTOs. This change that would “lead to expansions in service for Somalis without a meaningful increase in the banks’ own reputational or legal exposure” (p. 28). To encourage banks to be bolder, these authors write that “US Treasury Department officials, particularly in the Office of the Comptroller of the Currency (OCC), should build their understanding of Somali-American MTO compliance practices and encourage banks to open accounts for responsible companies” (p. 28). These authors also recommend that the Treasury Department bolster “the security of the remittance system by facilitating the creation of a shared clearinghouse based in the US,” an action that “would aggregate all transactions originating from all MTOs and agents, thereby helping regulators and MTOs identify remitters sending funds through multiple MTOs” (p. 28).

4.0) Improve Nutrition and Health Services
UNICEF has devised evidence-based strategies to mitigate childhood malnutrition in developing countries. In what follows, (4.1) these strategies will be briefly outlined, and then (4.2) ways to best implement them in Somalia will be explored.

4.1) UNICEF strategies for mitigating childhood malnutrition. UNICEF (2012) outlines a strategy for preventing diarrhea in developing countries. This strategy consists of the following steps: “increasing coverage of the rotavirus and measles vaccines,” “promoting early and exclusive breastfeeding and vitamin A supplementation,” “promoting hand washing with soap,” “improving water supply quantity and quality, including treatment and safe storage of household water,” and “promoting communitywide sanitation” (p. 44). The report notes that diarrhea interventions tend to be inequitably implemented within developing countries, as richer areas generally receive disproportionately more interventions (p. 38). If poor households in these countries received the same number of interventions, then, according to one model, the number of children under the age of five dying of diarrhea would decline by 60 percent (p. 38).

UNICEF (2009) outlines a strategy for combating childhood malnutrition in developing countries. This strategy is guided by the insight that growth faltering in children begins very early in life and that “the window of opportunity for preventing undernutrition” is small, lasting from pregnancy until the age of two (Victora, de Onis, Hallal, Blössner, & Shrimpton, 2010, p. 473). The UNICEF program consequently focuses on four main interventions.

First, the program seeks to improve the nutrition of mothers before and during pregnancy by providing “supplementation with iron, folic acid or mul tiple micronutrients and provision of food and other supplements where necessary” and also by educating women about “appropriate behaviours to improve nutrition” (UNICEF, 2013, p. 18).

Second, the program tries to educate mothers about the importance of breastfeeding within an hour of birth and engaging in “exclusive breastfeeding for the first six months of life and continued breastfeeding up to the age of 2 and beyond” (UNICEF, 2013, p. 19). Research has shown that “optimal breastfeeding of children under two years of age has the potential to prevent 1.4 million deaths in children under five in the developing world annually,” and yet the practice “is not widespread in the developing world” (Cai, Wardlaw, & Brown, 2012, pp. 1, 4).

Third, the program advocates giving families complementary foods and teaching the importance of complementary feeding. “Studies have shown that feeding with appropriate, adequate and safe complementary foods from the age of 6 months onwards leads to better health and growth outcomes” (UNICEF, 2013, p. 21). “Multiple micronutrient powders (MNPs) offer a low-cost, highly acceptable way to improve the quality of complementary foods (p. 25).

Fourth, the program seeks to ameliorate micronutrient deficiencies, as “[v]itamin and mineral deficiencies are highly prevalent throughout the developing world” (UNICEF, 2009, p. 23). “Adding micronutrients to staple foods, complementary foods and condiments in factories and other production sites is a cost-effective way to improve the micronutrient status of populations (p. 25).

4.2) Ways to Implement These Strategies. Social workers should improve Somalia’s nutrition and health services by (4.2.1) coordinating with the Somali government, (4.2.2) integrating nutrition services with health facilities, and (4.2.3) educating at the community level.

4.2.1) Coordinating with the Somali government. Nutrition programs work best with the involvement of the national government, which is generally best suited to coordinate services (UNICEF, 2009, p. 39). The Ethiopian government recently began combining “nutrition services into one comprehensive strategy,” and has seen childhood stunting rates decrease significantly (UNICEF, 2013, pp. 28-29). Similarly, in recent years the Rwandan government has led an effort to scale up “community-based nutrition programming to all of the country’s 30 districts” and has seen stunting rate among children under five fall from 52 percent to 44 percent in just five years (UNICEF, 2013, p. 37).

4.2.2) Integrating nutrition services with health facilities. UNICEF has had some success integrating nutrition interventions with existing health facilities. For instance, workers at the health facility in Baidoa make sure to “dispense crucial information on feeding and hygiene practices to the mothers [it cares for], such as handwashing and child feeding” (“Nearly 56,000 Somali children,” 2015). They also give the parents of younger patients “a supply of ready to use therapeutic food (RUTF),” “a nutritious peanut-based paste which they can give to the child to eat at home” (“Nearly 56,000 Somali children,” 2015).

Many Somalis never go to health facilities. Aid workers are responding by forming traveling health teams. For instance, the Outpatient Therapeutic Programme (OTP) is “a team of nurses traveling from village to village across the region, holding regular clinics checking and treating sick children,” or treating children before they become so sick that they need hospitalisation (Pflanz, 2011). Similarly, the Joint Health and Nutrition Programme (JHNP), aware that “[m]ost Somali women give birth at home without professional assistance,” is training a team of midwives to assist in these home births (“Joint Health and Nutrition Programme,” n.d.). A logical next step would be to train these traveling workers to also impart important nutritional information to patients and if possible to provide patients with RUTF.

4.3.3) Educating at the community level. Aid workers have also had success working at the community level. UNICEF strives to establish “infant and young child feeding programs at the village level, where mothers learn the importance of breastfeeding, proper nutrition and home hygiene and sanitation from trained community workers” (Makundi, 2015). Similarly, the NGO Medair uses community health workers “to actively seek out children in rural areas who are showing signs of childhood malnutrition” (“Community-based approach to malnutrition,” n.d.). These workers then refer the children “to an outpatient therapeutic feeding program” and also “encourage home-based special feeding regimes and provide enhanced access to oral rehydration salts and zinc” (“Community-based approach to malnutrition,” n.d.).

Conclusion

Somalia’s childhood malnutrition problem is severe and its consequences devastating. Yet the world community has the means to support the Somali government and relief agencies in their fight to defeat this problem. It is up to social workers to remind the public of their obligation to support this fight and to advocate for evidence-based solutions.

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