I’m managing our emergency response program addressing malnutrition in Niger for a few weeks. For those who work in the aid sector, you probably have a fair idea of what that actually means. For the rest (those of you who are interested), here’s what we’re doing.
First, some background, so we’re all speaking the same language.
Malnutrition, simply put, is the state that results when a person’s body doesn’t take in enough nutrients- the chemicals that allow our body to function correctly, which we do generally by consuming a balanced and sufficient diet. Malnutrition can be due to the overall food/calorific intake being too low, a poor diversity of food-groups, or an illness that inhibits the body’s correct processing of those chemicals. Malnutrition has a large number of indirect causes, and a large number of direct results. Key among the latter are nutrient deficiencies, poor physical development (‘stunting’), rapid weight-loss (‘wasting’), susceptibility to disease and, in extreme circumstances, death (although direct death through malnutrition is relatively rare- it is more likely to be caused by disease which is more virulent in a body weakened by malnutrition).
We deal with two main types of malnutrtion: Long-term, or ‘chronic’ malnutrition, and short-term, or ‘acute’ malnutrition. Chronic malnutrition exists where populations consistently lack access to sufficient or balanced diets, or are exposed to regular and frequent cycles of acute malnutrition. Acute malnutrition exists where there are substantial short-term shortages in food availability.
Niger experiences both chronic and acute malnutrition. It is a landlocked country which is two-thirds desert, so growing food is a challenge. Rainfall is erratic and unreliable, and the desert encroaches into arable land. Roughly 90% of its agricultural harvest is a single crop (millet) which grows well under the circumstances, but means that diets are unbalanced. Traditional childcare norms (non-exclusive breastfeeding, early weaning and poor hygeine and sanitation practices) mean that children are health-disadvantaged from an early age. So the background chronic malnutrition is high, primarily among children. It means childrens’ bodies do not develop as well as they should. They are stunted (small for their age), and their brains may also not develop as well as they would have with a good diet. It has huge implications for Niger’s development as a country.
The harvest is brought in once a year. Depending on how good the harvest is, villages will have enough to eat. However stocks will dwindle through the year, so as the months go by, people will drop back to having two meals a day, one meal a day, and sometimes not even eat every day. This is known as the hardship or hunger season (saison de soudure). The onset of the dry season (February through May) reduces the availability of wild foods, and also puts herds of cattle under pressure. The worse the prior year’s harvest, the earlier this hardship season begins, the more pressure this puts on communities’ abilities to cope, and the deeper the crisis.
The rains traditionally arrive in late June (although as the world’s climate changes, they are becoming increasingly erratic and unreliable) and last until September. This enables the next year’s harvest to grow and flourish- depending on how good the rains are. It also brings with it malaria. The relationship between disease- especially malaria and diarrhoeal disease- and malnutrition is such that children who are malnourished are more likely to get sick because their bodies are not as well equipped to defend themselves; and children who are sick are less able to maintain their nutritional status. It is a vicious cycle.
These factors then give rise to acute malnutrition. In Niger, acute malnutrition traditionally starts to rise from May and June and continue until after the harvest in October, but on a bad year may begin to spike in February, and can last throughout most of the year, with substantial caseloads still recorded in November and December. It affects mostly children, and mostly those children under the age of five. Child deaths also spike during this time. It is inevitable, and the less work that is done to manage acute malnutrition, the more children will die. We focus on children because physically they have the fewest bodily reserves to handle shortages of food and therefore they become malnourished quickest, and also die quickest. It’s worth noting that children who are chronically malnourished already will be the first to drop into acute malnutrition once food runs out.
There are different ways to manage malnutrition. In refugee camps, malnutrition is typically done on-site in feeding centres, where women bring their children to receive a cooked ration directly from the supporting organization. ‘Wet ration’ feeding centres are expensive to run, as they require staff to prepare and distribute the food, often for hundreds of children at a time, but they work well in relief-camp settings where tens or hundreds of thousands of people may be in one physical location which can be easily accessed- so they are efficient. The biggest advantage is that staff can actually watch the malnourished children receiving the ration, so they know it has been received.
In a peace-time context like Niger’s, where rural populations are low and spread over large areas, wet feeding centres are too expensive to put into every village, and distances too great to expect women and children to travel to twice a day. The solution is a model called Community Management of Acute Malnutrition (CMAM), which brings women to distribution points once a week or once a fortnight to receive a ration for their child, which they take home and give their children as instructed. This has the advantage of being far more affordable to reach a population spread over a large area, but requires trust that the women will in fact give their children the ration- not always the case, when they might have two or three other children at home also not eating properly.
The first stage of the program is ‘screening’. Community volunteers are trained to identify children in their village who they suspect could be malnourished. They encourage those children’s mothers to take them to the nearest government health-centre.
There, program staff working alongside government health workers assess the children for malnutrition. This is done using something called a MUAC (mid upper-arm circumference) tape, which goes around the child’s bicep to assess how badly wasted it is (apparently that circumference does not change greatly in young children above the age of six months). It is marked in millimetres to measure the actual circumference, and colour-coded. A green reading indicates the child is healthy, a yellow reading indicates moderate acute malnutrition (MAM) and a red reading indicates severe acute malnutrition (SAM).
If the child is malnourished, it is then weighed on a hanging scale, then placed on a measuring board to take its height (which generally encourages loud wailing from the hapless child). The child’s weight for its height is then assessed against the average weight for a child of that size; obviously, the lighter a child of a particular weight, the thinner it is. These measurements are taken at intervals while the child is in the program to track changes in its weight. Additionally, they are assessed against a chart of ‘z-scores’ which plots the average weight for a child of a particular height. If the child is more than two standard deviations below the average weight for its height, the child is moderately acutely malnourished, and if it is more than three standard deviations, the child is severely acutely malnourished.
It may sound a bit technical, but in fact it takes no more than half a minute per child using MUAC, or ninety seconds to weigh, measure and score children using weight-for-height. The child’s information (name, village, score) is then recorded on a health card which is given to the mother- blue for moderates, and pink for severes. Program staff also assess children for possible medical complications (e.g. malaria, oedema), and if these are present, children are refered to an intensive care facility, managed by another organization.
So to sum up, we have four categories. Healthy, Moderately Acutely Malnourished, Severely Acutely Malnourished, and Severely Acutely Malnourished with Medical Complications. Our program looks after the moderates and the severes. And because the physical needs of moderates and severes differ, we treat them differently.
Moderates receive a bi-weekly ration of a reinforced meal-mix (‘reinforced’ meaning the staple has had things added to it to increase its nutritional value). This is usually a cereal flour (in our case Corn-Soya Blend, or CSB), sugar and oil, mixed together. Mothers take this home and feed their children the ration over two weeks, then return to have the child re-measured for progress and receive another ration (if required).
Severes receive a weekly ration of therapeutic food. We use a product produced locally in Niger called Plump’ynut. Each ration is self-contained in a small foil packet and tastes like sweetened peanut butter. It is specifically designed to address severe acute malnutrition, and generally speaking, the kids (and, sadly, sometimes the adults too) love it.
There are tweaks to the program beyond this, but this is the core. Our biggest challenges include ensuring the malnourished children receive the ration they are supposed to, and that it isn’t shared with other children (or worse, adults). In fact it’s not unusual for mothers to deliberately underfeed their children so that they remain on the program, so that they can continue to access the food ration which can contribute to their whole family’s wellbeing. Sometimes, an additional ration is given to the families of malnourished children to try and prevent this from happening.
The harvest is slowly coming in. Between now and mid-October it will be gathered, and during this time the food situation in the villages here will gradually improve. Malnutrition levels will lag- October is the peak malnutrition month historically. Millet is fine for adults, but kids under two will not get its full nutritional benefits (we push as hard as we can for mothers to keep breastfeeding). During the 2005/6 crisis we were still seeing kids in the program as late as April and May the following year, and I’d certainly expect to see some of the same patterns this time round.
The nice thing about working on a nutrtion program- as opposed to many other programs aid and development workers can often get involved with- is the short-term horizon. It’s normal for us to phase out of a place and never actually see the work that we do bear much fruit, beyond, perhaps, the provision of some basic goods and services. Here, however, it’s pretty easy to tell when a really sick kid shows up at the nutrition centre. Most of the kids in our severe program are ill enough that if they were to get malaria or cholera, they could die in a matter of forty-eight hours. Getting them out of that state and to better health is the aim of the program, and if the mother is feeding the child the ration, stays in the program, and the child doesn’t get ill during this time, then we can turn them around in a matter of four to six weeks. The really sick ones- the ones we refer straight on to the intensive care clinics- may only have lived a day or two past when they come to us.
It really is the business of saving lives out there. The teams on the ground (across several organizations) do amazing work, and there are many children who will live who would otherwise have died without their assistance. It’s a privilege to be able to drop in and be a part of the work they are doing for a few weeks.