Childhood Malnutrition and the Dinka of Southern Sudan

By Vikki Groves

Vikki Groves has a MA in Medical Anthropology from the School of Oriental and African Studies in London. She has worked on projects in India, Kenya, Tanzania and Southern Sudan and currently works in research for a UK-based charity.

Special thanks to World Vision Sudan for commissioning this research and giving the author the opportunity to work with the communities of Tonj South. Thanks too, to the Dinka community members themselves and to all those who shared so willingly their time, customs, traditions, beliefs and knowledge with a western anthropologist fascinated by their way of life.

This article is a summary of a report¹ commissioned by the international humanitarian organisation, World Vision, to investigate the impact of social and cultural factors on childhood malnutrition amongst the Dinka of Tonj South County, Warrap State, Southern Sudan.

Southern Sudan is one of the least developed regions in the world. Decades of civil war, ethnic tensions and climatic changes have left its agricultural production and infrastructure in tatters with few hospitals, schools, roads or businesses. Levels of childhood malnutrition are of major global concern. According to the 2006 Sudan Household House Survey, 31% (one in three) of children under the age of five years in Sudan were moderately to severely underweight². World Vision data (2006) for Warrap State found 14.1% of children were severely underweight³. In Tonj South County, the global acute malnutrition (GAM) prevalence (WHZ⁴ <-2 SD scores) was 20% (15.2-24.8, 95% C.I) whilst the severe acute malnutrition (SAM) prevalence (WHZ <-3 SD scores) was 3.7% (1.8-5.5 95% CI) (June, 2009⁵).

The determinants of malnutrition amongst the Dinka of Tonj South County are known to be many and multi-faceted. Reduced crop yields as a result of climatic conditions, conflict and poverty play a significant role. However, this research identified that there are a number of cultural factors that could have a significant influence on the nutritional status of children, pregnant women and lactating mothers in Tonj South County and that these factors can and should be taken into account when designing future nutrition programming.

Mothers cooking in Tonj South, South Sudan

Research methodology

This article focuses on the Rek Dinka of Tonj South County, Warrap State. It is primarily based on social research carried out in the region between November 2009 and February 2010, with some additional available information. Research was conducted using ethnographic methods that included quantitative and qualitative techniques. At the end of the study, 15% of the total 151 villages in Tonj South County were visited and interviews, focus group discussions (FGDs), questionnaires, informal discussions and direct observation conducted. A total of 100 in-depth interviews, 14 FGDs and 163 questionnaires were carried out.

Study limitations

This study offers a valuable insight into the cultural traits of the Rek Dinka in Tonj South County during the four month study period. However, it cannot be assumed that all Dinka sub-clans behave in the same way and it must be recognised that behavioural patterns will change at different times of the year. This research was influenced by the deterioration in the security situation in Tonj South during the period of fieldwork. This affected the research timetable, influenced which communities were visited and prevented many evening visits. Mechanical problems and poor road conditions further hindered data collection and limited access to certain communities.

Background

The Dinka, also known as the Moinjaang, are a Nilotic people made up of several independent groups linked by ties of kinship, which together form the single largest ethnic group in southern Sudan. Traditionally the Dinka are transhumant pastoralists whose cattle form the mainstay of life and culture, with small scale agriculture and subsistence farming supplementing their livelihoods. Cattle, however, have remained essential to the identity of all the Dinka people and are used as the medium of exchange for virtually all Dinka transactions, including marriage, payment of debts and as a sacrifice to the spirits.

The prevalence of acute malnutrition in children in Tonj South remains at an unacceptable level. Standard assessment approaches of nutritional surveys, which consider GAM and SAM prevalence, and food security assessments, which examine harvest levels and food stocks, have been undertaken in the county but have been unable to uncover the underlying causes for this level of malnutrition.

Key findings

The following factors represent some of the most significant characteristics known to influence nutritional status and that are relevant to this ethnic group:

Awareness, understanding and treatment of malnutrition

For the Dinka of this region, the reasons and causes of malnutrition in children are explained through a series of traditional beliefs. These affect treatment patterns and choices, as well as the speed with which health centres or Community Therapeutic Care (CTC)/ Community Managed Acute Malnutrition (CMAM) services are sought. The Dinka believe that if a woman has sex whilst breastfeeding, the male semen entering her will "travel to her breast" and poison the breastfeeding infant.

For this reason, women will abstain from sex whilst nursing infants, which means that birth spacing is relatively well managed. However, the most common reason for women to stop breastfeeding is for her to have more children and to start having sex with her husband again. This can have a negative impact on existing children under the age of two years who therefore have a shortened period of breastfeeding and are sent to cattle camps (see below) at a younger age.

A group eating in Makuei, Tonj Payam, South Sudan

Traditional beliefs also surround the concepts of Jong-nar-lou and Jak-nar-lou, which focus on the need to please the disgruntled spirits of the maternal uncle or maternal grandmother, respectively. These spirits are thought to make children become "thin, old-inthe- face, and sick", and can only be appeased by having an offering made to them either directly (if they are still alive) or through their living relatives. These offerings must include a bull, a goat and a chicken, which are valuable household resources. Many parents will wait until malnutrition has reached an advanced state in their children, having first exhausted traditional health provider options and having made their offerings to the spirits, before seeking treatment from a health centre for advanced forms of acute malnutrition.

Distribution of food at the household level

All meals are prepared by women. Men do not generally know how to cook and if they do, they do not do so. Women will spend several hours preparing food over open fires and when it is ready, they will divide it up onto large plates that are given to different 'groups' to share. Groupings differ slightly between households but it is usual for groups to include one for young children, another for older children, one for the husband and men, and another for women. Extra groups may include young men, visitors and grandmothers. Groups will share food from one dish. Children are usually, but not always, watched by their mothers to ensure that each child has an equal share.

The order of who is served first is the choice of the mother. The women and mother of the household will always eat last, even if pregnant or breastfeeding. They will sit with younger children and encourage them to eat their food. There is no sex bias affecting which children eat first or the quantity they receive. However, there is a tendency for women to give larger quantities of food to the men of the household, often serving themselves smaller, inadequate portions.

Ideally Dinka families will eat three times a day but frequency of food intake is subject to seasonal change. Currently, food shortages are such that it is not uncommon for some households to eat only one meal a day. Children will eat with the rest of the household and are more vulnerable to malnutrition because they are unable to ingest large quantities of food in one sitting.

Dinka society is polygamous and most men have more than one wife. The number of wives a husband has affects how much time he spends within that household, which in turn affects the quantity of food available for other family members at meal times. It also affects the age at which children are weaned (cease breastfeeding). Favouritism between wives leads to the unequal distribution of a husband's often limited resources, e.g. money to make purchases at the market.

Sharing

The Dinka operate within a cultural system that is both egalitarian and kinship based. As a result, all food is shared in equal parts among all those present. Whether related by kinship or even as strangers, most Dinka households will share their food with all those present. This action is based on the belief that all people can 'meet again' and by feeding a stranger today, he could feed you tomorrow. The practice of sharing food greatly impacts the quantity of food available for children within the household. It also makes targeting food aid difficult, as there is a definite discrepancy between the number of persons living within a household and the actual number of people eating at that household. There is little data available on the prevalence of malnutrition among adults. It can reasonably be assumed that prevalence is high, certainly within the more vulnerable groups such as women, young children or the elderly, as they have the least access to dietary supplements such as wild food sources.

Pregnancy and lactation

Children are extremely important within Dinka culture as they provide labour, protection (when they grow up) and cows (in the form of a 'bride-wealth⁶' paid by a groom's family to a girl's family to finalise a marriage alliance). It is difficult to estimate the average number of children a Dinka woman will have in her lifetime - like many African cultures, Dinka men and women view talking about the number of children they have, or pregnancies had, as bad luck. Cultural beliefs and practices towards pregnant women, with regard to diet, behaviour and work ethic, impact birth weight, the nutritional status of newborns and the health of new mothers. Women consistently perform the same daily duties (including walking long distances for water or firewood, pounding sorghum, sweeping the compound and cooking) up until the actual day of delivery. Diet remains as it was before pregnancy with no additions of specific food groups or increases in quantity. Pregnant women are also influenced by a number of taboo foods that can limit sources of protein; this is particularly significant during the months of the year when cow's milk is unavailable.

Although the breastfeeding period typically excludes solid foods for infants aged 0-6 months, water is often introduced sooner. Drinking water tends to be untreated and given from dirty jerry cans or cups, exposing young children to pathogens that affect their health and nutritional status. If a mother is severely malnourished, the quantity and quality of breastmilk produced and her capacity to care for her young infant will be negatively affected. Protecting the nutritional status of mothers-tobe before and during pregnancy and during lactation is important to ensure maternal reserves are not depleted during breastfeeding, to preserve vitamin and mineral adequacy of breastmilk, and to ensure adequate nutritional status and birth weight of newborns.

Cattle camps

Cattle camps play an important role within the Dinka culture and are the scene of all major social activities. Young men, unmarried women, grandmothers and children all live in large camps to tend to, milk and protect cattle. During the dry season, the camp moves to where the water source is greatest, often a far distance from the villages they are from. All children are sent to the cattle camp to be weaned and to 'forget their mother's breast'; many will be very young when they arrive and will be taken care of by grandmothers or male relatives. This practice places young children, typically until the age of five years, in a dirty and dusty environment where their diet is restricted to cow's milk only, although porridge is sometimes introduced sooner. Microbial contamination of cow's milk is common and often results in intestinal irritations and infections that lead to diarrhoea, constipation or other illnesses. This diet of cow's milk alone is inadequate for a young child recently weaned, as it does not contain the micronutrients needed to meet the demands of a growing child. There was no evidence of cow's milk being mixed with the blood of cattle as a means of fortifying the milk and boosting iron intake.

Weaned children will either remain on the cattle camps to assist their fathers and grandmothers or return to the village to be with their mothers and assist them in their daily duties. Older siblings will often help their mothers to look after younger babies. It is rare to see one Dinka child alone, and commonplace to see children of five or six years old balancing a baby on their hip or soothing the tears of a younger sibling.

Hygiene

Knowledge, even a basic awareness of germs and how they are spread, is very limited amongst most Dinka communities, particularly those living in rural areas. Whilst cleanliness is considered important, it can often be a low priority for households with limited resources to purchase soap or for those living long distances from a water source. As a result, people, including children, do not wash their hands frequently. This increases the risk of disease transmission during food preparation, eating and other activities such as infant care.

Conclusions and implications for humanitarian programming

This article highlights some of the significant social and cultural practices and beliefs that were identified during field research as negatively impacting child health and nutrition status in Tonj South. In order for nutritional programming to be more effective here, or in any setting, it is imperative that these sociocultural factors are understood and targeted in programme design. In the case of Tonj South, it is important to target nutrition programming at all levels of the community. Women should be targeted with nutrition education that emphasises eating a balanced diet, of adequate proportions, both during pregnancy and during the post-partum period, whilst men and grandmothers should be targeted, as the primary care-givers of children at the cattle camps, with nutrition and behaviour change communications.

Cattle camp scene

Nutrition education should also be incorporated into water, sanitation and hygiene and livelihood projects to emphasise and explain to people the connection between hygiene and diet with health and nutritional status.

In any context, it is essential that local nutrition workers receive full training and education in the fundamental causes of malnutrition and that their trainers are cautious not to make any assumptions regarding their worker's basic levels of understanding. Training must cover more than simply learning how to measure and weigh children to identify malnutrition. Local staff are the public voice of humanitarian agencies and must lead behavioural change by example, so that proper health education is passed on to the community and produces lasting change.

For more information, contact Vikki Groves, email: vikki.groves@hotmail.co.uk

¹Childhood malnutrition and the Dinka of Southern Sudan. An exploration into the cultural and social determinants of malnutrition in children under five years of age in Tonj South County. By Victoria Groves, Consultant Anthropologist, March 2010. Commissioned by World Vision Sudan.

²Sudanese Government of National Unity and Government of Southern Sudan. (2006). Sudan Household Health Survey, Sudan: Sudanese Central Bureau of Statistics/ Southern Sudan Commission for Census, Statistics and Evaluation.

³World Vision (2006) Tonj South Community Nutrition and Survival Project.

⁴Weight for height z score, using WHO 2006 Growth Standards

⁵Pertet, A. (2009) Report of Nutrition and Mortality in Tonj South, Warrap State, South Sudan.

⁶Bride-wealth' is a system of marriage payment whereby the groom's family transfer wealth to the family of the bride at marriage in order to cement the union.