COMMENTATOR (COMM): Previously on Life...

DR IKLAS MUSTAPHA: Most of the pregnant women here, they are suffering from anaemia.

NEELAM ADHIKARI: Literacy of women, education, hygiene, availability of food; the whole situation is is really socio-economic.

DR DEBBIE DANIELS: What really should be happening is that governments should be providing basic needs - providing for the basic needs of their community.

COMM: Niger lies on the southern edge of the Sahara desert in Africa, landlocked between Nigeria to the south and Algeria to the north; it's one of the poorest countries in the world. Most people live in rural areas. They scrape a living off the land - herding livestock and growing the staple cereal, millet. There's just enough to eat - but there's a hidden hunger among almost all the women and young children, caused by iron deficiency anaemia. It's an unseen problem, that slowly steals away the body's strength and immunity to disease. Zalika was so severely anaemic she collapsed after she gave birth - she had to spend two weeks in hospital.

ZALIKA (TRANSLATION): I was feeling dizzy and my body was dying. I couldn't stand up on my own.

COMM: Zalika's just one of the two billion people around the world who lack iron - an essential micronutrient. In Niger's rural areas, pregnant women rely on the knowledge of village birth attendants like Zeinaba to help them through childbirth. In Tourikoukey, in the west of the country, three-quarters of the women are anaemic. It's so common there's a word for it in the local language - it's 'lack of blood'. Zeinaba knows many of the women she visits daily suffer from the problem - but there's only so much she can do.

YOUNG MOTHER (TRANSLATION): I still have a pain in my stomach, I'm coughing and vomiting. I can't see and I can't hear well. I'm not eating - I can't taste anything.

ZEINABA (TRANSLATION): Have you been to the hospital?

YOUNG MOTHER (TRANSLATION): No, I went there when it first started but I'm not getting any better.

COMM: Without enough iron in the diet, the body can't make red blood cells. In turn there's not enough oxygen, causing dizziness and extreme tiredness. But even when anaemia is severe, the only visible evidence is paleness.

ZEINABA (TRANSLATION): I can't really tell if someone is actually anaemic - you can't tell until they say they feel dizzy, their body aches and they feel exhausted. When you have all this, I've been told the eyes become white and you can be sure that there is a lack of blood - so I heard.

YOUNG MOTHER (TRANSLATION): I do want to go to the hospital. But I don't have the money to go - I need it to feed and take care of the children. People like us who feed themselves day by day - how can they have enough to go to hospital?

MOTHER-IN-LAW (TRANSLATION): She hasn't been well since the baby was born. He was born when there was no food to eat and we're struggling to feed ourselves day by day. We have no money to go to the hospital.

COMM: Niger's beleaguered health services don't reach most communities. This means supplies of donated iron supplements distributed by the Ministry of Health don't get to the women who really need them.

DR AMADOU BOUKARI, Head of Nutrition, Ministry of Public Health, Niger (TRANSLATION): Iron deficiency needs a particular strategy because the dose isn't weekly, monthly or quarterly - we have to give it every day and it is very expensive. Also the channels of distribution and the health coverage are both very weak - about 32 or 34%.

COMM: Helen Keller International - which works in Niger - believes it's local midwives like Fadima who can play a vital role in supplying women with the extra iron they need. In the western district of Tera, Fadima has the responsibility for handing out iron folate tablets in her village.

FADIMA (TRANSLATION): Before we started, women were not feeling well. One day she would be standing, the next, she wouldn't be able to get up. The women couldn't eat - they didn't have enough blood to make them healthy. I was told to distribute only to pregnant women, so even if I lack blood I'm not allowed to take the tablets. Even in my house there's a girl who is the same age as this girl who is 16. She is always eating but she still hasn't got enough blood.

SHAWN BAKER, Regional Director for Africa, Helen Keller International: You're really just scratching the surface of the problem with pregnant women because in a country like Niger women are going into pregnancy anaemic. During the adolescent growth spurt, the levels of need for iron are extremely high - they go up dramatically - and girls marry very young here - often 15 or younger. So you're starting this vicious cycle that girls are anaemic - they go into their first pregnancy anaemic - and they never recover between pregnancies.

COMM: It's early days. Just one in ten women benefit from this new village based distribution scheme. To improve on this depends on more people like Fadima who take their work seriously.

FADIMA (TRANSLATION): The tablets have been brought for pregnant women. Any pregnant woman can come and we count out 30 and give them to her. The pregnant woman feels better and so does the baby - and when it's time for the woman to give birth it'll be easier.

COMM: Since 1999 the Government has organised micronutrient days for the whole of the country, twice a year. Launched by the Head of State -Tandja Mamadou - they're much publicised events aimed at increasing awareness about nutrition across the country. But this year, the essential role of micronutrients in the diet has been dwarfed by food shortages.

TANDJA MAMADOU, President of The Republic of Niger (TRANSLATION): There has been shortages in Niger this year and we know the most vulnerable are mothers and children. The government has taken charge by providing the population of Niger with cheaper cereal - to the mother and child in particular - so that this section of the community will be saved from the situation in which we are living since last October. And thank God the programme from Bilma to Tera has helped and - as you see - there are no images of emaciated people and the mother and child haven't been forgotten.

COMM: In Tera, families still hope for rain as they continue to plant this year's millet crop. Millet is their staple diet - but it's this diet that contributes to anaemia.

SHAWN BAKER: The basic diet is cereal based and cereals have phytates which inhibit the absorption of iron so you have - that's one of the fundamental problems. Animal sources of iron such as meat or especially liver are very good but herds often are seen more as capital than something that you consume on a regular basis. Even if you are going to eat meat products in a family, who's going to get them? Er traditionally men are going to get the choicest portions - and so the actual amount of, for example, liver that would get to women or to children is relatively low.

COMM: Kopto is a meal eaten every day in Tera district. This is what Fadima and her family are eating tonight. It's millet, a little flour mixed with oil, salt and green leafed amaka.

FADIMA (TRANSLATION): Meat! If we do have meat it'll be while before we have it again. We eat it about three times a month we share it out with everyone. It is expensive: two hundred West African francs buys enough for only a little piece each.

COMM: Anaemia in pregnancy almost always leads to mothers giving birth to low birthweight and anaemic babies. These children are especially vulnerable as they lack the strength to fight off disease. In Niamey's paediatric hospital, Dr Boureima sees three thousand malnourished children, every year.

DR BOUREIMA, Paediatrician, Niamey Paediatric Hospital (TRANSLATION): It's the same problem: completely malnourished. She's both malnourished and anaemic. We know anaemia is the fourth cause of hospitalisation in the service in terms of numbers. These are the severe cases but practically all children who are suffering from malnutrition are anaemic as well - plus the other causes of anaemia, whether it's malaria or severe infection. This department in the hospital, it's the one which uses the most blood. It's very white. He has chronic anaemia and if he's got malaria - as malaria is a cause of anaemia - the anaemia becomes worse and this can kill him. You understand, the cause of death is not anaemia it's the malaria that kills the child. It's the same problem - very, very white. What do you know about lack of blood - how do you know if you have anaemia?

MOTHER (TRANSLATION): Yes, lack of blood - if it's not yellow fever, it means your body's lifeless. It's as if the body that dies.

BOUREIMA (TRANSLATION): We know that anaemia affects the intellectual development because not enough oxygen is transmitted in the nervous system and in the body's tissues.

COMM: Helen Keller International and the United Nation's Children's Fund, Unicef, are the main contributors to the national iron supplementation programme in Niger. Even so the majority of women and children - six out of every ten - still miss out. One problem is that the Government hasn't allocated specific funds for nutrition.

DR AMADOU BOUKARI (TRANSLATION V/O): In all the speeches you hear people saying nutrition is a priority. But in practice, when you look, you can't see allocation of the budget for nutrition. It is said it is a priority. But the resources don't reflect that this is so - whether it is financial or human resources. For all Niger, there are less than 10 qualified nutritionists. In other words, the need to promote nutrition for human development has certainly not really been recognised yet.

COMM: Fati lives in Aviation on the outskirts of Niger's capital Niamey - she's eight months pregnant and has malaria. Malaria is one of the major causes of lack of iron in the body. After Fati was bitten by mosquitoes, the parasites in her body started destroying the red blood cells and caused severe anaemia. Fati's baby will also be deprived of iron.

FATI (TRANSLATION): I've been to the hospital and had some blood and urine tests. I've spent 7500 West African Francs and they told me that I lacked blood. Look at my hands and my eyes! I'm dizzy and I can't stand for long when I'm dizzy it always makes me vomit. I find it difficult to stand up on my own. When I went to the maternity hospital I met many women with the same problem -they all complained about malaria. At seven months and fifteen days my son died - in my womb - I was very sick at that time. Yes, like now.

COMM: It's a vicious cycle. Malaria causes blood loss - then the body, weakened to infection - can't fight off malaria when it returns. On the other side of the continent in Tanzania, anaemia is getting worse. The coastal region from Kenya in the north to Mozambique in the south is a malaria zone. Anaemia affects almost all children under five in the 82 villages in Bagamoyo district.

FATUMA (TRANSLATION): One week it's the mother - the next, it's the child. You can say this is the biggest disease that we have here, this malaria. It's a big problem because sometimes a person is told, month after month, they have to go to Muhimbili hospital. And here it's difficult to get out of this village every time to go there and get check-ups.

COMM: Malaria kills one child every thirty seconds. Those that do survive are more susceptible to recurring bouts of infection. In neighbouring Mwanamakuka, schoolteacher, Fatuma Mtamba, sees the effects of malaria daily.

FATUMA MTAMBA, Primary School Teacher (TRANSLATION): They become very weak and, even in class, they can't concentrate because they are tired all the time. And in class their brain becomes slower and slower and they get worse every day. They can attend for three days and then they're absent for two. Sometimes they attend in the morning but then not in the afternoon because they are so weak Because of the malaria they become anaemic and then they get malaria again. So they don't attend daily lessons properly. And if they don't attend lessons they lose their intellectual ability.

COMM: The Tanzanian Food and Nutrition Centre is working with four health centres in Bagamoyo to try and replace the iron lost in children due to malaria.

DR SABAS KIMBOKA Director of Community Health and Nutrition, Tanzanian Food and Nutrition Centre: We are intervening. We are giving children - children below the age of five years - iron syrup, and we are deworming them and we will follow them up to see if there is going to be any impact. The children must go to a health unit in order to get these supplements and the deworming drugs. So if the child don't attend it means it is going to miss the next provision of the supplement. But you find that the number of children that attended last month has dwindled - has gone down. Sometimes the drugs many be there but the health worker does not know that he or she should prescribe these.

FATUMA (TRANSLATION): There were some tablets that were given for a week, but other people got them. I don't know what the tablets were for. The children were given syrup in a bottle to drink from one week to the next - Friday to Friday - that's what they gave the children and that's what I gave my children. But I didn't know what it was for.

DR SIRIEL MASSAWE, Obstetrician, Muhimbili Hospital, Dar Es Salaam: There isn't much awareness. And this is partly because the health facilities, especially in rural areas, have not - do not screen the women because if we were able to screen the women, and tell them what their haemoglobin levels are then that is an opportunity to explain what anaemia is and what they can do about it. I think the strategy for the control of iron deficiency, especially in women has been really hospital based - or health system based. So that assumes a real working health system especially at primary health care system. And, as you know, our primary health system is not working.

COMM: Differing views among health scientists have left iron deficiency control programmes floundering, unable to provide clear guidance.

MEERA SHEKAR, Senior Project Officer, Unicef, Tanzania: We tended to believe earlier that in areas where malaria is endemic - that iron may in fact increase the risk of malaria - now we know that this is not the case. And so we need to pursue the iron supplementation more aggressively but at the same we've got to deal with malaria in a different way as well - preventing malaria.

COMM: In Kibuyuni village, Bagamoyo, Mitamaa's unusual: she bought a mosquito net when her first child was born nineteen years ago.

MITAMAA (TRANSLATION): To buy one now - it's three thousand three hundred Tanzanian Shillings. I don't have that money because I can't afford it - I mean, I live by farming - I dig cassava and I use this to feed my children. If I sell the cassava what will I feed my children with? How can I buy a net? This is my net. This is where my children sleep - all of them - two on this side and other two on that side. I cover them and these are the parts I've repaired - as long as the children don't get bitten by mosquitoes. The children are playing all day after in the evening after they've eaten and been washed - if you put them to bed they will be so tired they can't feel the mosquito when it bites but me as an adult if I feel anything - I just hit it. No, I can't afford to buy another net for my husband, myself and my children. My income is very low I've got to struggle on with it just for the sake of my children.

DR KIMBOKA: So long as poverty reigns in this part of world all these problems will continue to be afflicting us. Poverty alleviation first and then supplementation as short term measures can just be sort of stop gap measures, you know?

MEERA SHEKAR: In the short term - or even in the medium term - we don't see diet alone as sufficient in terms of improving iron intakes and so supplementation is something that would probably need to be continued on a medium term if not long term basis.

COMM: Iron folate tablets have been distributed to mother and child clinics in Tanzania since 1974. But there's been almost no progress in reducing the rates of anaemia.

MEERA SHEKAR: Iron is a much more complex problem. It's a problem that programme and policy makers themselves - until a few years ago - have not been very clear about what to do. And perhaps that is one of the reasons why we haven't made as much progress with iron. We haven't necessarily focused enough on adolescent girls for example, and those adolescent girls are a very, very critical group as far as iron supplementation is concerned - as far as anaemia, malaria and iron supplementation, all three of those, are concerned.

COMM: In Tanzania, 16 per cent of pregnancies are women under the age of 18. Theresa Idiva sees many young mothers daily at Mbagala Clinic in Temeke, on the outskirts of Dar es Salaam.

TERESA IDIVA, Assistant Medical Officer, Mbagala Round Table Clinic, Temeke: We are trying our best to make sure that these young mothers - we take time to talk with them we have to screen them we give them health education and how to take care of their health and nutrition and so forth. You know these pills, although I giving the mothers, we are not sure if they are taking the pills. Because you can check the haemoglobin at this month. Then at the second visit when they come you can find the haemoglobin maybe lower than the previous month. Now, you ask the mother, "Did you really take these drugs?" and she says "Oh no, when I took the drugs, I vomited" you know? Or, "I feel abdominal or discomfort."

COMM: Iron is not well tolerated by body, particularly when it's deficient of other micronutrients. It's another problem to overcome in finding solutions to prevent iron-deficiency anaemia. It's also going to take a big education push to promote good nutrition and the importance of eating iron rich foods before the rates of anaemia go down, as Dr Kimboka recognises.

DR KIMBOKA: We have a problem of sustainability in our country and in many, in many developing countries - sustainability. You find a project like this is supported from outside, and it's short lived. So when the supporters are ready to pull out you find the country is not ready to take over.

MEERA SHEKAR: In many, many governments, nutrition is something that falls between the Ministry of Health - sometimes the Ministry of Planning, sometimes the Ministry of Agriculture, in the case of Tanzania, it's the Tanzania Food and Nutrition Centre. So it's something that falls between all of these Ministries, and in the process nobody really ends allocating enough resources for nutrition.

DR KIMBOKA: For about 15 years now, we've been implementing Structural Adjustment Programme under the World Bank and International Monetary Fund. Before that the funding for social services in this country was a bit better but from that time, things have become worse and worse. Social services are not funded and we are servicing external debts, that's the problem. So with cancellation of debts, we think that we'll be able to put more funds into health services - including nutrition - and we should be able to sustain some of these projects which we are initiating.

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