Sudan has one of the highest malnutrition rates in the Middle East and North Africa region. For the last forty years, one third of the population has suffered from irreversible chronic malnutrition - a life-long growth condition that has consistently plagued Sudanese children since 1987.
Now, more than two million children are already stunted and unlikely to ever reach their full growth potential. 17% of Sudanese children are acutely malnourished and over half a million will suffer from life-threatening severe acute malnutrition during one year (UNICEF S3M 2013).
Ibrahim (left) and Amna (right) are the same age. Amna stopped breastfeeding at 11 months due to her mother's next pregnancy and is visibly more stunted than Ibrahim, who is also malnourished.
Despite these harrowing figures, there has been a substantial shift in approaches towards combating the issue. As recently as a few years ago, malnutrition was a taboo topic - stigmatised and unacknowledged by policy-makers. Today, the government is working hand-in-hand with NGOs to treat and prevent malnutrition at local council level, all over the country.
"From a country point of view, looking back three or four years, malnutrition was not well- positioned in the national developmental agenda. It was a very sensitive issue and its existence was somehow denied. Over the last few years, we have managed to make a big strategical shift in the policy environment through advocacy work and mobilisation to alert the government that malnutrition is a real problem, not something we have to hide, rather it is a problem we have to tackle," says Talal.
A presidential decree was passed in 2015, assigning board of various ministries and government bodies to combat malnutrition on a national scale. Sudan has now qualified to join the global movement SUN as the 56th country and are eligible for technical, financial and structural support from the international community, despite isolating US sanctions.
In a country where nearly half of the population live under the poverty line, a lack of financial stability has a knock-on effect on both food insecurity and the availability of health care. Cultural frameworks also play a big role in the high rates of malnutrition, where small practices have a big impact.
Karr Sheikhf, 12 months of age, rests on his mother's lap after being breastfed during his admission at the clinic for malnourished children in Kassala.
Family practices, such as hygiene and breastfeeding habits, are directly influenced by poverty and the dire state of girls' education in Sudan. Female literacy rate for girls in rural areas is as low as 39% (UNICEF 2014) meaning that mothers can rely heavily on misleading cultural knowledge.
"There are many causes for malnutrition such as social norms and beliefs, for instance, there is a belief in east Sudan, that if a child or pregnant woman eats eggs the infant will go deaf. When a child is born, one of the foods that are crucial for growth are eggs which are rich in protein. So, they are denied protein at the most fundamental stage of development, " says Talal.
In the west of Sudan, particularly Darfur, one prevalent tribal practice is the removal of a child's frenulum - the muscle under the tongue. This creates problems for food intake and even breastfeeding. These deeply-rooted belief systems can contradict basic infant nutritional needs.
"A UNICEF and Ministry of Health Knowledge, Attitude and Practice study, conducted in four states in 2012, showed that there is a widespread belief that introducing water during the first six months of a child's life is important because of the hot weather, This practice affecting negatively the exclusive breast feeding for six months. We design messages to address this issue and promote the understanding that a mother's breast milk is initially 87% water then the child gets protein and then fats at the end of one breast feeding episode," says Talal.
Weaning children off of breast milk too early can severely stunt growth and compromise immunity. Women are often pressured to do so on the advice of their mother, aunts and peers - making malnutrition a community awareness issue.
Haleema Ibrahim feeds Plumpy Nut, a ready-to-eat therapeutic food provided by UNICEF, to her 2 year old daughter Asha Ibrahim at the Wad Sharifa health centre.
"We found that addressing many people with one message was not working. So now we are moving towards one-to-one counselling all over the country, talking to the specific mother about her specific problem. This sequence of counselling is designed according to the lifecycle approach, starts from pregnancy and ends with the first two years of the child's life through a huge networks around the country and functions within existing community structures, where trained local counsellors attend a natural community gatherings such as coffee gathering and mother meeting groups," says Talal
UNICEF trains leaders from the Women's Union who have the power to mobilise the community. They act as regional facilitators for a six-day course on infant and child feeding counselling, after which the trained local counsellors set up mother support groups where they are each responsible for ten homes. The counsellor will monitor new mothers from pregnancy through to the first two years - a period known as the 'window of opportunity', ensuring proper feeding practices such as exclusive breastfeeding for the first six months and regular check-ups and weight monitoring.
"We currently have records of 6,600 groups all over the country and contact information for 6,600 mother support group leaders, " says Talal.
UNICEF treatment rates are currently over 80% and the death rate is below 5%.
"We are moving towards a strategic change in Sudan in terms of economical investment, where we are not just focusing on petrol and oil, we are investing in people as the most important resource Sudan has," says Talal.
"I don't just feel the change, I see it. "
All photos courtesy of UNICEF Sudan.