MSF nurse Desma Anindo measuring the malnutrition levels of children under 5 at the Paliang supplementary feeding centre. A line of mothers wait with their children. Photo © James Lorenz/MSF

In 2005, after 21 years of war, a peace deal was struck between the Sudanese government and rebel groups operating in the south of the country. But for thousands of people in the southern Bahr El Ghazal region, violence and starvation remain a daily concern.

With the rains failing in 2004, much of the population in Tonj County has virtually nothing to eat. The poor harvest of the staple food – sorghum - was consumed long ago, so for the past few months people have been reduced to eating leaves from trees and diarrhea-inducing nuts.

"It has come to the point where mothers have to make the choice between which child they are going to feed, as they don't have enough for them all," says MSF nurse and medical team coordinator, Patrick Murphy. "This is a terrible choice for any mother to have to make."

The worst is to come

The worst period has not even begun and already 20 percent of the population is 'moderately malnourished,' according to a recent MSF nutritional survey. The rains have once again come late, which does not bode well for the September harvest.

Currently the hospital therapeutic feeding center (TFC) is filled with 120 children under five years old. "But we are only seeing the tip of the iceberg," says Murphy, from Chico, California, "for every child in here, there could be another 20 in the same situation that we haven't reached."

A major reason for the unknown levels is access—the nature of the region limits MSF's ability to reach the people and their ability to get to MSF.

At the Paliang supplementary feeding centre. a boy watching his mother cook leaves to eat. Photo © James Lorenz/MSF

In Tonj County, medical facilities, roads, and schools are rare in the extreme. Two decades of war have assured this. To travel the few miles from the MSF hospital in the main town of Marial Lou to the feeding center in Paliang takes more than an hour across a parched landscape only punctuated by occasional huts and clutches of thorny trees.

MSF has been running the hospital in Marial Lou since 1997 and has set up five feeding centers to deal with the dramatic rates of malnutrition. The centers provide food for the moderately malnourished, with severe cases referred to a therapeutic feeding center situated inside the hospital.

Southern Sudan is no stranger to starvation. In 1998, it is estimated that more than 60,000 people died as a result of famine. While 2005 is unlikely to reach this level, the hunger is devastating and the first victims are the youngest children.

The physical effects on the young children are striking. "The malnourished babies have sunken eyes and thin discolored hair," says Desma Anindo, an MSF nurse who runs the Paliang feeding center. "They look like old men."

At the Paliang feeding center, children are weighed and measured to check their nutritional status. MSF provides them with supplementary food when required.

A long line of mothers and their children, listless with hunger, wait to be seen. Many have walked for miles in search of food. One child lies naked in the dust, barely able to move. Another mother cradling her baby squeezes her breast, showing the MSF team that she has no milk. She is too malnourished to produce any milk. "The situation is very bad," Anindo says. "Dying is a matter of days, not months."

But once inside the Marial Lou therapeutic feeding center, the recovery of the severely malnourished children is striking. "Within a week they go from being on the verge of dying to behaving like normal healthy children again," says Patrick Murphy.

Violence over cattle

There is scarce pasture for the cattle in southern Sudan. Cattle serve as currency, as well as a vital source of nutrition. Now they are dying or ghostly thin, unable to provide milk. Some lie dead on the edge of villages.

With failed rains increasing the pressure on available pasture, clashes have flared up between the two main ethnic groups in southern Sudan—the Dinka and the Nuer.

Cattle raiding have also been on the increase, serving only to add to the impoverished state of the inhabitants of Tonj. Violence is not limited to clashes between Dinka and Nuer. Around three hours drive to the north of Marial Lou, regular outbreaks of fighting have occurred in recent months between two Dinka clans, the Aliek and the Langkap.

The violence has spiraled, forcing people to head south into the already impoverished regions around Marial Lou. The violence has also blocked off important grazing and fishing areas, further adding to the crisis.a

"The people here are desperate," says Murphy, "they need food aid urgently or many more people will die." At the moment though, despite the many promises from the international community, nowhere near enough assistance is forthcoming.

A region on the edge

In the Upper Nile province the situation is little better. Again, failed rains compounded by continuing violence are leaving thousands starving in the region. In the town of Leer where MSF runs another TFC, 80 children were admitted in the first two weeks of May, nearly three times the number for the corresponding periods in 2003 and 2004. "And we are expecting this to get worse over the next few months," says MSF head of mission Tom Roth.