Acute malnutrition: A highly prevalent, frequently fatal, but treatable, neglected disease
Regular starvation in Niger and beyond
Debate ensued over the nature of the Niger crisis in 2005 and the appropriateness of the response, as international relief efforts were finally stepped up in July. There were objections to the use of the term famine to describe the emergency, and resistance to providing free food aid as a response until late into the hunger gap period, when food reserves from the previous year's harvest were exhausted, and the steep price of staple food items on the market had broken all previous records.
Niger is a country with chronically high levels of what Nobel Prize winning economist Amartya Sen calls "regular starvation".
Other terms used are chronic hunger or under-nutrition. The Food & Agricultural Organization estimates there are over 800 million undernourished, having access to less than their daily requirement in food energy to be normally active. Economists view chronic food shortage in such large populations as a failure of development.
Many public health advocates actually play down the link between food scarcity and childhood malnutrition in poor countries, insisting instead on "inadequate infant and young child feeding practices", or, to a lesser extent, on poor access to health services or clean water.
Outside of major crises, the usual proposed package of preventive and curative child health interventions rarely includes the treatment of even the severest cases of acute malnutrition.1 Severe acute malnutrition defines a form of malnutrition that bears a particularly high risk of death but which nevertheless responds rapidly to treatment.
Individual cases are diagnosed either on the basis of the degree of emaciation or "wasting," as measured by the weight to height ratio, or by the circumference of the mid-upper arm (marasmus); or by the presence of "water in the tissues" (oedematous malnutrition or Kwashiorkor). Moderate cases of acute malnutrition are those with a slightly less abnormal weight to height ratio. Unicef estimates there are over 60 million children suffering from acute malnutrition (wasting) at any given moment.
Thirteen million of them are severely wasted, whilst many others are affected by Kwashiorkor. Acute malnutrition is implicated in over five million preventable deaths yearly amongst young children.2 The Maradi region alone accounted for 39,353 admissions for severe malnutrition to MSF therapeutic feeding programmes in Niger in 2005.
Over 95% of cases occurred amongst children less than 30 months old, and the majority (over 60%) were admitted during a three-month period between mid-July and mid-October corresponding to the classic hunger gap (over 80% between June and November).
Yearly admissions in Maradi were four times higher than the number admitted into the MSF programme in 2004. In some southern, rural cantons of Maradi in 2005, almost half the children between six and 24 months of age developed severe acute malnutrition during the year and were admitted to an MSF therapeutic feeding programme.
It is inconceivable that infant and child feeding practices can account for such large seasonal and yearly variations in admissions for severe acute malnutrition in Niger. Nor can this variation be explained by increased exposure to disease and poor access to healthcare or clean water. Such variations are largely due to nutritional stress in the hunger gap period, particularly in years following poor harvests. At these times, the quality and limited diversity of the diet is often even more limiting than the caloric and protein content of available food.
Over the past 20 years, clinical nutrition research has increasingly concentrated on the role played by micronutrient dietary deficiencies, typically associated with the monotonous, cereal-based diets of rural-poor populations, in growth failure and malnutrition. Deficiencies in trace metals, sulphur, phosphorus, certain vitamins and other micronutrients have particularly deleterious effects on young children in the first two, critical years of life.3
Many easy-to-use, fortified, nutrient-rich products specifically designed for this age group to help prevent deficiency exist on the market in developed countries for those with the means to purchase them. Any attempt to reverse the high rates of malnutrition in countries such as Niger has to address the difficulty poor, rural populations face in providing a sufficiently nutrient-rich diet for their young, rapidly growing children.
Stepping up the treatment of acute malnutrition
Results obtained in Niger in 2005 in rehabilitating large numbers of severely malnourished children are exceptional.
Over 91% of severely malnourished patients from Maradi region (34,247 children) exited the programme cured, that is, no longer acutely malnourished.
Providing individualised, therapeutic treatment to such large numbers of patients had never been accomplished in the large famines of the recent past in Ethiopia, Somalia and Sudan. What has changed? Until recently the World Health Organization (WHO) recommended that all cases of severe acute malnutrition be treated with therapeutic (high energy, nutrient fortified) milks, in therapeutic feeding centres or inpatient wards of hospitals.4
Although high cure rates are obtained by humanitarian agencies using therapeutic milks in feeding centres during major crises, such specialised centres represent a significant investment in staff and infrastructure, are costly, and have limited capacity at any one time.5 Moreover, demands on a patient's family posed by prolonged inpatient feeding (generally several weeks) discourages participation, lowers programme coverage and increases the number of children who default before cure.
It is not completely surprising then, that outside large emergencies, the treatment of severe acute malnutrition has not been seen as a priority by international public health consultants, and that few countries with limited resources have made attempts to integrate the treatment of acute malnutrition into their healthcare services.
In the case of Niger, a country where there are, depending on the season and year, between 250,000 and 500,000 acutely malnourished children at any given time, no effective nutritional rehabilitation programmes for severely malnourished patients existed outside the MSF Maradi programme until July 2005.
The introduction of Ready to Use Therapeutic Foods (RUTF) over five years ago is changing perceptions and practices.6 These nutrient-rich products designed for rapid weight gain do not require preparation or the addition of water, and the energy- dense paste is impossible to contaminate.
They are tailored for malnourished children with poor appetites and small stomachs who need to consume high quantities of calories. Small, severely malnourished children can gain one to two kilograms in a few weeks.
These factors make such products ideal for outpatient use, and mothers quickly grasp the therapeutic nature of the product. The MSF experience in Niger in 2005 shows that most cases of severe, acute malnutrition can be cured through attendance at outpatient centres at regular, weekly intervals. Over 65% of severely malnourished children were admitted directly into outpatient care, and the majority never required hospitalisation during the entire course of their treatment. Almost 85% of all admissions finished their treatment as outpatients. The average time to cure was less than a month.
Inpatient units are needed to handle referrals for complications such as anorexia, weight loss, severe infection or anaemia.
There were almost 1,000 deaths amongst patients admitted to MSF inpatient centres in Maradi in 2005; however, over 6,200 others were discharged cured or referred back to an outpatient programme after having spent less than two weeks on average as inpatients.
The availability of a simple to use and effective therapeutic product permitted MSF to admit record numbers of patients into its feeding programmes in Niger in 2005. Such new products and strategies open new possibilities for nutritional intervention in large emergencies, and in situations with high levels of childhood malnutrition.
In Maradi in 2006, MSF is treating all malnourished, severe and moderate, with the same therapeutic treatment regimen. The severely malnourished have higher rates of mortality, but most malnutrition-related deaths occur amongst the far more numerous, moderately malnourished group.
On an individual level, all are at increased risk of death and disease, and most can be quickly cured when the best available therapeutic, nutritional product is given to them. MSF is looking at ways to further simplify outpatient management of acute malnutrition. By reducing the frequency of follow-up visits, it is possible to further increase capacity and efficiency, helping mothers who have to travel significant distances to attend scheduled consultations.
It may be possible to bypass the time consuming procedure of taking each child's height and rely on the measurement of the mid-upper arm circumference (MUAC) and weight alone. Some of these new ideas are currently being implemented in northern Kenya, where three years of drought have led to high malnutrition rates amongst pastoral populations.
Clearly, efforts to address the underlying causes of malnutrition are critical and must be supported. However, new therapeutic products and outpatient treatment strategies make it possible to offer curative treatment now, to much larger numbers of patients, including in situations of chronic hunger, where most cases of acute malnutrition and excess death are occurring. This will be all the more true if RUTF products can be made less costly and more widely available.
There is no reason why this can't be done. As treatment of acute malnutrition becomes simpler and cheaper, it may no longer be perceived exclusively as a tragic dilemma requiring sustained, long-term efforts and solutions, but also as a highly prevalent, frequently lethal, neglected and imminently treatable disease, calling for immediate and effective medical care.
FOOTNOTES 1. Jones G et al. How many child deaths can we prevent this year? Lancet 2003; 362: 65-71.
2. Black RE et al. Where and why are 10 million children dying every year? Lancet 2003; 361: 2226-2234.
3. Shrimpton R et al. Worldwide timing of growth faltering: Implications for nutritional interventions. Pediatrics 2001; 107: e75.
4. Golden MH, Briend A. Treatment of malnutrition in refugee camps. Lancet 1993; 342:360.
5. Collins S. Changing the way we address severe malnutrition during famine. Lancet 2001; 358: 498-501.
6. Briend A et al. Ready-to-use therapeutic food for treatment of marasmus. Lancet 1999; 353: 1767-1768