The banana trees were destroyed by a landslide triggered by an aftershock, and the cost of moving to a new location placed a huge strain on the family. Even the older children, aged five and seven, eat mostly vegetables and lack protein in their diets. At the hospital - an expensive 10 kina (about $4) round trip by bus from her isolated village - she was able to get counselling and packages of the vitamin and energy-enriched children formula Plumpy’nut. Israel's story is echoed across the Highlands of Papua New Guinea. An isolation ward in the Mount Hagen Hospital where underweight newborn babies are treated. Equipment and training were part of UNICEF’s emergency response to the earthquake. Credit:M. Dozier/UNICEF The earthquake struck at around 3am on February 26 last year, killing about 100 people and displacing more than 20,000 - many of whom were already extremely vulnerable.

It does not take much for a natural or man-made disaster to push people in these areas over the edge. The earthquake exacerbated underlying issues which have been prevalent in this Pacific country for decades. Loading “Malnutrition is a big problem here, not just because of the earthquake," said Paediatric Medical Officer Dr Rose Hosea. "Most of the mothers are not educated enough to provide balanced meals to their babies. Education is the main issue here." The quake has hit almost 550,000 people in five provinces, displacing almost 20,000. It destroyed roads, bridges, hospitals, schools and other vital public infrastructure. It damaged garden plots and interrupted water supplies.

Aftershocks continue to this day. A teacher at the Koroba District Learning and Empowerment Project, said the water in her village had disappeared overnight when streams were covered by landslides. Teacher Thresina James did not teach her grades 1 and 2 classes for several months after her school was heavily damaged. “I miss my students,” she said. An underweight baby is kept warm in an isolation ward in the Mendi General Hospital. Credit:M. Dozier/UNICEF Most families rely on subsistence farming – growing vegetables on small garden plots – so landslides and blocked rivers dealt a significant blow to people’s livelihoods. More than 200 aftershocks have rocked the region and continue to this day.

It is not uncommon to see low birth weight babies or malnourished children at some of the healthcare facilities in the region – an indication that families are struggling to make ends meet. “People are trying to survive on what little they have,” said a well-known local chief and politician, Damien Arabagali. According to the Asian Development Bank (ADB), the earthquake caused a 1 per cent drop in Papua New Guinea’s GDP in 2018 due to disaster-related challenges and a slowdown in public spending. A major LNG facility in Komo, near ground zero and operated by Exxon Mobil, was closed for several months. There was also major damage done to the privately-run international airport and to health facilities in the area. Yolit Somol watches over his malnourished son Japheti, 3, in the paediatric ward of Mendi General Hospital. Credit:M. Dozier/UNICEF Among the social problems that the earthquake exacerbated was lawlessness. While a sense of normality is taking hold, tribal fighting continues to slow efforts to bring a full recovery.

Philip Undialu, the governor of Hela province, which was created in 2012, said the earthquake exacerbated an already fragile law and order situation. “The little investment we did here in the last five has been demolished by the earthquake and the law and order issue," Undialu said. "Both the natural and man made disasters have brought the province down.” Students travelling to schools near Lake Kutubu. Thousands had their education interrupted by the earthquake. Credit:M. Dozier/UNICEF Few international agencies or donors are active in the region, and even diplomats based in Port Moresby are reluctant to come to the highlands due to security concerns.

The United Nations has used the earthquake to undertake its first-ever proper mapping of the region, and has, in the past year, established a semi-permanent presence. UNICEF's PNG head David Mcloughlin said the agency was providing humanitarian and early recovery support for children and mothers - including distributing school supplies – students bags and education supplies and teachers' kits – to 10,000 children and 3000 teachers in 66 elementary and primary schools in both provinces. They hope the UN's presence will encourage other development partners and donors to take an interest in the neglected Highlands. A young girl gets her arm measured to determine if she is malnourished. Credit:M. Dozier/UNICEF But at least twice last year during the UN’s relief response, operations had to be suspended because of violence in the key regional cities of Tari and Mendi. The airport in Tari is now able to accept commercial flights, but a larger airport in Mendi is still closed after violence destroyed the terminal building and an aircraft belonging to the national carrier. Rural schools are yet to return to regular operations, with many still closed or working out of tents. Parents and teachers say pupils are often kept at home because of tribal violence.

“When the fighting starts, the parents don’t send their kids to school,” said Alice Bibe, who runs a UN-supported women’s empowerment program in Hela Province. In many parts of the mountains, valleys and forests that make up this land, clan fighting is endemic and gender-based violence is common in the home. Teachers and parents cite outbursts of fighting for children missing out on school. Children enjoying water from a tap in the village of Humbra, Southern Highlands. The restoration of water and sanitation infrastructure was one of the priorities of the UN in the aftermath of the earthquake. Credit:M. Dozier/UNICEF Schools and homes have been burnt down and children have been caught in the line of fire, teachers and activists say, though exact numbers are hard to come by. Local leaders say conflicts have become more lethal because powerful guns smuggled in from across the border with nearby Indonesia are replacing traditional bows and arrows.