Once known as the bread basket of Somalia, the central regions of Lower and Middle Shabelle are today gripped by the worst malnutrition emergency seen in this part of the country for many years.
"People have not been able to plant their fields, feed their children," says Christian Balslev-Olesen, the UN Children's Fund (UNICEF) country representative for Somalia.
"Food production has been hit in a dramatic fashion," he adds. "There has been a substantial increase in the number of people fleeing the conflict in Mogadishu [the Somali capital] and now the Shabelles are faced with an imminent threat of flooding as river banks have not been maintained due to conflict and the lack of local capacity."
According to UNICEF, limited access to essential services because of ongoing conflict, significant deterioration in food security and a recent diarrhoea outbreak associated with poor water and hygiene conditions, have resulted in global acute malnutrition rates of 17 percent - 2 percent above the emergency threshold.
Of 83,000 children who are estimated to be malnourished in South and Central Somalia, 35,000 are in Middle Shabelle. Of these, 8,700 are severely malnourished in Shabelle and at greater risk of death, say UNICEF staff in Jowhar, the regional capital.
Another nutrition assessment in September by the UN Food and Agriculture Organization's Food Security and Analysis Unit in 10 locations found acute malnutrition rates above 20 percent among children under five, and clear signs of kwashiorkor.
Recurrent flooding has affected water quality and hygiene conditions and destroyed crops; poor crop production has resulted from poor Gu (long) rains, leading to the rapid inflation of food prices and disrupting economic activities, in turn worsening the situation.
These cumulative shocks, say aid workers, have adversely affected the nutritional well-being of the population in rural riverine and agro-pastoral settlements, as well as in urban areas. For example, 25 percent of the people recently displaced from Mogadishu are in Lower and Middle Shabelle.
Even then, there will be no quick recovery unless civil security improves and the Deyr (October-December) short rains are normal. Yet forecasts show this to be unlikely. Worse still, the response to the situation has been slowed by the absence of many international organisations, lack of government capacity and inadequate support for national NGOs.
"Given the high level of malnutrition, you would expect to see many high-profile NGOs and agencies all over the place," says Balslev-Olesen. "But you do not see them because of the security situation."
Aid workers point to continuing violence in Mogadishu, 90km from Jowhar, as the key to the humanitarian crisis in central Somalia. "The economic status of the population was heavily depressed by the Mogadishu security situation and the cost of some food commodities has risen," says James Kingori, UNICEF's nutrition cluster coordinator. "The IDP [internally displaced persons] influx into the Shabelle added to the burden of an already depressed host population."
Fighting intensified in Mogadishu in December when a combined force of Somali and Ethiopian troops expelled the Union of Islamic Courts from the city. Since then, widespread violence has forced civilians, especially women and children, to leave the city and seek refuge in camps such as Sheikh Omar in Jowhar.
According to UN estimates, more than 400,000 people fled the city between February and May. Some 115,000 returned between May and June, but another 40,000 left in July and August.
Poor rains, flooding and crop failure
In recent years, Somalia has experienced poor rainfall, flooding and crop failure in varying degrees. "We have had floods along the River Shabelle - the worst in December 2006," says Hussien Mohammed Dhere, deputy governor of Middle Shabelle.
"On the other hand, when you go east of here, they have not had rain for two years. Then you have the seaside communities that have not harvested any crops since the [December 2004] tsunami. And 50km west of Jowhar, there is no health facility."
The situation has prompted the few agencies operating in the region to scale up operations. The UN World Food Programme (WFP), for example, has increased the number of people it aims to feed - 1.2 million - although it needs US$20 million to continue operations beyond October.
"The crop failure, flooding and poor rains meant they could not get back to their original levels of food security," WFP's Chris Baron said in Dhaygawan, just outside Jowhar, where the agency was distributing food rations - part of a consign ment of 578 metric tonnes targeting 29,000 people.
The economic status of the population was heavily depressed by the Mogadishu security situation and the cost of some food commodities has risen
Feeding the children
Gently pressing the foot of five-month old Shukri Mohammed at Sheikh Omar centre in Jowhar, where 800 families that fled Mogadishu over the last six months are camped, Kingori explained: "This child has mild oedema and is in urgent need of nutritional rehabilitation. If response is delayed or if any further deterioration occurs in its condition, it may be too late."
The little girl was one of more than 100 children being screened for malnutrition on 25 September. "We are finding that about half the children are malnourished or at risk of malnutrition," Mariam Sheikh, a local NGO leader, who coordinates the preparation of an enriched meal of porridge for the affected kids.
"We will refer some to the nearby therapeutic feeding programme within Jowhar regional hospital," she said. The programme is managed by an Italian NGO, Intersos, in partnership with UNICEF.
The camp, named after its founder, is a cramped settlement in Jowhar town located near the Shabelle river. Most of the IDPs were originally from Jowhar and had moved to Mogadishu. But violence has forced them back home.
Omar said the main problems facing the displaced people - mainly women and children - include sanitation, food and shelter. "And the numbers are rising every day," he told IRIN.
"I came here with my five children," explained 30-year-old Ubar Abdille, who runs the kitchen. "I left this village to go to Mogadishu to get married - and came back because it was the only village I knew."
Asked why she did not simply rejoin her family, instead of staying in a camp, Abdille said: "They are not any better. No one here can help the other; in fact if peace returned I would go back to Mogadishu."
Aid workers say the high number of malnourished children in the camp is representative of the broader situation. The more severely affected ones, including those outside the camp, are taken to feeding centres or to hospital.
Matanei Abraha, health project manager at the Jowhar regional hospital, said 112 malnourished children have been referred in the past five months, while another 467 have been treated in villages and six IDP camps in Jowhar.
"The capacity of the country to support the normal growth of children is a problem," said Grace Kyeyune, UNICEF's resident programme officer for Central-South Somalia. "There are families where up to four children have grown up in a feeding centre."
According to a 2006 inter-agency indicator survey, under-five mortality improved from 224 per 1,000 in 1999 to 135 per 1,000 in 2006, while access to safe water rose from 23 to 29 percent over the same time.
"When 70 percent of a population have no access to clean water, you will have diarrhoea again and again," said Balslev-Olesen. "And we are talking about a population in which only 22 percent of the children go to school."
Twenty feeding centres for malnourished children have been set up in Middle Shabelle, but there is still little coverage outside the riverine areas and in Lower Shabelle.
"We need more partners here," said Balslev-Olesen. Greater international NGO involvement and more support from Somalia's transitional government were crucial, he added.
"The Somali transitional government needs to remove obstacles to humanitarian work - insecurity, taxation and closing some airstrips," he adds. "Other international organisations also need to scale up their presence. It is a question of capacity."