"Losing my child while I am watching is breaking my heart," says Mohammed Yousuf as he tries to calm his crying son. "I feel so worried for my son. I won't rest until my son is completely healed."
Yousuf lives in Yemen. His 1-year-old son, Abdullah, has been at a health facility in Sana'a, the capital city, where doctors are feeding him reconstituted milk from powder formulated for children with malnutrition to keep him alive.
On Dec. 5, Abdullah weighed 6 pounds on his fifth day of treatment for severe acute malnutrition, says his attending clinician, Dr. Abdelmalek Mohammed. That's less than one-third of the average weight for his age. The doctor's diagnosis of severe acute malnutrition is a medical classification reserved for the worst cases. Yousuf and his wife, Fadiah, traveled 15 hours by bus through dozens of military checkpoints to bring their child to the facility in Sana'a. He spoke to NPR by phone.
(NPR has withheld the family names of the parents and doctor because of concerns about their safety.)
In Yemen today, 1 in 5 children are severely malnourished, according to U.N. reports. The five-year-old civil war has caused the country to plunge deeper into poverty that has been exacerbated by floods and locusts. And even when there is food available, a 3-year-old, Saudi-led blockade restricts goods coming into the country by land, sea and air. The resulting delays increase the cost of basic necessities like food.
And for many Yemenis, any price is too high. Yousuf lost his job as a farm laborer last year when farmers couldn't get diesel, required to run the pumps for irrigation and drinking water, because of fuel shortages caused by the war. Now his family depends completely on aid, which he says allows them to eat one small daily meal.
In fact, 80% of Yemenis depend on aid. And it's often not enough to avert tragedy. Yousuf says his two older children died of malnutrition: his firstborn at age 6 months and his second child at 4 months. He says both children died during treatment at a health center near their rural village in Taiz, which he says lacked medicine and staff.
Fighting in Taiz makes it difficult for parents to get medical attention for their children, says Samuel Mbuto, a nutritionist specializing in severe child malnutrition for the humanitarian group International Medical Corps. Mbuto has worked through two previous famines, first in his native Uganda and then in Southern Sudan. Conditions in Yemen, he says, are much worse because the blockade restricts access to aid. This is his third year in Yemen.
During his nine years of practice, Mbuto has measured the arm circumferences of many children, a major indicator of malnutrition. He uses a small tape-measure-like device called a MUAC tape (mid-upper arm circumference). He wraps it around the child's arm like a hospital bracelet, inserting the end of the tape into a slot and pulling it through to adjust to the width of the arm.
If the arm circumference is in the range of about 5 to 10 inches, the child is in the green zone, indicating a healthy size. From 4.5 to 5 inches on the tape is a narrow yellow section that indicates moderate malnutrition. Then the MUAC tape is red from 4.5 inches until it ends. When children measure in the red zone, they have severe malnutrition. Mbuto has seen arms that measure as little as 3 inches around in Yemen.
At the 27 facilities where Mbuto manages nutritional programs, he says that nearly all the children he sees measure in the yellow and red parts of the tape. Mbuto says the signs of malnutrition are evident in their sunken eyes, diarrhea, ribs protruding in sharp relief and knees like "chicken drumsticks."
"Once the child is sick, their faces show sadness, the mother is also sad, then you see signs of hopelessness," says Mbuto. "They don't know what will happen the next day."
He says recovery can require up to two months of close monitoring and feeding.
Other doctors interviewed by NPR have witnessed similar distress. Dr. Wafa'a Al-Salali leads a team of nutritionists for International Medical Corps in southern Yemen. She says most of the children admitted to their health centers are severe cases. Her colleague, Thorya Sallam, a nutritional nurse in western Yemen, says the feeding centers are crowded, and malnutrition cases are compounded by cholera and diphtheria.
"When I see the children in the feeding ward I am fearful and worried," says Al-Salali. "Watching the collapse and weakness of the health system is the most difficult thing for me as a doctor during the war."
At the health center in Sana'a, Dr. Abdelmalek Mohammed measures and weighs children during visiting hours. He tells NPR he believes that one-year-old Abdullah, with an arm measurement of 3.2 inches, will survive. The doctor says a few beds away is a severe case that he thinks will also survive, 16-month-old Zayed Ali. After a month of treatment, Zayed weighs the same as Abdullah, 6 pounds, with an arm circumference that measures 2.8 inches, roughly the size of a wine cork.
The doctor has seen an influx of families traveling from distant rural areas of the country seeking medical care for their children in the capital. He says it's a significant indication to him that malnutrition has worsened.
Even if a child like 1-year-old Abdullah survives and is discharged from the feeding center, his parents will still have to continue his feeding treatment at home, says Mbuto, and if there is a lack of food at home, it is likely the child will relapse.
The U.N. predicts the situation in Yemen will worsen. It projects a famine in the next six months with well over half the country malnourished.
"Yemen is now in imminent danger of the worst famine the world has seen for decades," warned António Guterres, secretary-general of the U.N., in a statement last month. "In the absence of immediate action, millions of lives may be lost."
"The famine already exists," says Dr. Abdelmalek Mohammed, who sees only a couple of beds free in the feeding ward where he works — for now. "It has gotten worse to the point it has become out of control."