BARSALOGHO, BURKINA FASO Habibou Iba's twin sons are wasting away at the age of seven months after existing on a diet of millet and water.
The family was forced out of their home in January when their village in northern Burkina Faso was attacked as jihadist and ethnic violence escalated in the West African nation.
Aid agencies have distributed the typical rations of dry cereals, oil and beans, but what the children really need is milk, said Iba who is too weak to breastfeed.
"I am forced to beg in the village to buy them powdered milk," Iba, 27, said by phone from the town of Dori, where her sons are being treated for malnutrition by the medical charity Medecins du Monde.
Although awareness about malnutrition has increased in the last few decades, aid agencies still struggle to provide a balanced diet in poor, remote places, said several nutrition advisors for international charities.
With U.N. figures showing wars, persecution and other violence have driven a record 68.5 million people from their homes, more people than ever are dependent on food aid - and for longer periods, making it critical for rations to be nutritious.
In West Africa's Sahel region, which includes northern Burkina Faso, climate change and conflict have kept people in displacement camps for years with no end in sight. Mali has been in crisis since 2012, while Nigeria has been battling the Boko Haram insurgency for a decade.
"Historically, the concern has been about providing enough food in the context of emergencies, and this idea that an emergency is a short-term thing," said Corinna Hawkes, director of the Centre for Food Policy at City University of London.
"But the modern-day crises are not short-term. There's no question that the current world of food aid is not fully caught up with that modern reality."
U.N. figures show that the number of people in the world without enough nutritious food has been rising since 2014, reaching 821 million in 2017 compared to 784 million three years earlier. The vast majority live in Africa.
Poor diet has overtaken smoking as the world's biggest killer, according to the latest Global Burden of Disease study, causing 20 percent of deaths in 2017.
Malnutrition, or a lack of proper nutrition, occurs when there is not enough food or not enough of the right food.
About one in 10 children in Burkina Faso has acute malnutrition, according to the World Food Programme (WFP), when insufficient food or illness causes rapid weight loss.
Acute malnutrition kills, but a bigger long-term threat is chronic malnutrition, also known as stunting, which happens when a child has food but not enough nutrients to develop properly.
It affects about 20 percent of children under five worldwide.
Children who grow up eating rice or millet with no meat, milk, or vegetables, are at risk of stunting, which hinders cognitive as well as physical growth, said Fidele Rima, a UNICEF nutrition advisor in Burkina Faso.
"We have enough food, but we lost our animals," said Aibata Diallo, an older woman living in Barsalogho camp, a collection of tents set up in scrubland for people who fled violence.
Like other residents, she is surviving off basic rations: 400 grams of cereals, 100 grams of beans and 25 grams of oil per day, according to WFP, the U.N.'s food assistance agency.
Small children and pregnant or breastfeeding women receive fortified cereals, which partly replace the missing vitamins and minerals in their diet, but WFP said it still expects to see malnutrition spike among people who have left home.
"We're covering the basics. If we could do more we would want to do more," said David Bulman, WFP country representative for Burkina Faso, citing funding as the main constraint.
Aid agencies cannot distribute meat, milk or vegetables because it is too costly and even fortified cereals are not always available, aid workers said.
"In an emergency response it really depends on where we're getting the food that's being donated - that will matter for how much we can control the level of fortification and nutritional value," said Allison Oman Lawi, a senior policy advisor for East and Central Africa at WFP.
Sometimes donors send food or specify it should be sourced from a country in which fortified cereals are not produced.
Cost restrictions often mean choosing between quantity and quality, since cutting rations or targeting a smaller group can be the trade-off to afford nutritious foods, said Lawi.
"I have to make really difficult decisions," she said.
Distribution of rations was never intended to be a long-term solution but an interim until people start growing or buying food again, said Mamadou Diop, West Africa representative for global charity Action Against Hunger.
"What happens is that often we propose a minimalist approach, and the populations are obliged to turn to other mechanisms to regain their eating habits," said Diop.
These other mechanisms were still up for debate, he said.
Should people be given cash to buy meat and vegetables? What if there is none in the market or they spend it on something else?
Other aid workers agreed the goal was to move toward self-sufficiency - helping people plant gardens or start an activity that can generate income, even in a camp.
But the rising malnutrition rates in Africa suggest few people were phasing out of food aid. One fifth of people on the continent are undernourished, about the same as in 2005.
"I don't think we should be looking at providing assistance for years," said Bulman, WFP's Burkina Faso representative.
Aid experts noted malnutrition depended on more than food.
Children with diarrhea or worms from unclean water will not benefit from any amount of supercereals while aid workers know that recipients often sell rations to buy medicine or fuel.
"It's not as easy as just giving food and then there will be no more malnutrition," said Nathalie Avril, a nutrition advisor for medical charity Medecins Sans Frontieres.
Diversification and allowing people to choose food themselves should be priorities in long-term aid situations, she said, perhaps by using vouchers although this has challenges.
The last paved road disappears miles before it reaches Barsalogho camp, which is surrounded by sunbaked, barren land.
"I think everybody knows what to give, the point is that it's not easy to get it," Avril said.
Source: Voice of America