All the warning lights are flashing red this year: drought, the high prices of grains and fertilisers exacerbated by the war in Ukraine, reduced imports and speculation, numerous armed conflicts, a record number of refugees to be fed, disengagement of institutional donors,… With the exception of locusts, all the determinants of severe food scarcity are there, from Afghanistan to the Sahel, including Yemen, the Horn of Africa, and the Indian subcontinent. To the point of threatening all of the progress that was made in treating undernutrition after the 2005 crisis in Niger, which was the starting point for global advances in managing malnutrition in places where it is commonplace. It is time for a general mobilisation to limit the scale of the coming catastrophe. Interview with Jean-Hervé Bradol by Elba Rahmouni.

Malnutrition is an old problem. What does it bring up for a humanitarian doctor?

Being a social fact, the malnutrition due to intake deficiencies goes well beyond the medical context. In humanitarian work – understood as assistance to populations affected by war or disaster – the question of nutritional rehabilitation protocols is a settled one, at least in principle. I don’t mean that all our emergency operations for IDPs and refugees are successful, but that we have a framework – defined jointly by the World Food Programme (WFP), the WHO, and UNICEF – that works. We can use the nutritional supplements needed for good infant growth as early as possible. In certain situations, even using them in advance for entire populations of young children in precarious situations is considered acceptable. In our lingo, such distributions are called “blanket feeding”.

In which situations is combatting early childhood undernutrition most difficult?

In the chronically catastrophic situations in South Asia, Afghanistan and Yemen, in the Sahel, in the Horn of Africa, and in some parts of southern Africa. While this phenomenon does not affect the entirety of these countries, there are specific areas in certain regions where there are pockets of high mortality due to both malnutrition and infections. Those fighting this deadly combination (malnutrition and infections) in these historical foci are struggling to make progress. One of the biggest obstacles is the fact that children must reach the most severe stage of acute malnutrition before they are given ready-to-use therapeutic food (RUTF), despite the fact that such products have been proven effective. And only one out of four children who reach the stage of severe acute malnutrition is treated each year (The Lancet series 2013).

Which ideas are obstacles to early treatment?

The first is the idea that we have to eradicate malnutrition. When as a doctor you try to talk about malnutrition, the institutional donors and political leaders stop you and say, “We don’t want to invest in something with no hope of success.” They liken malnutrition to the basin of the Danaids, an endless task. The donors want a definitive solution, and one that has already been proven to work. But this makes things difficult, because there’s no definitive definition of malnutrition. It’s a nebulous concept that the WHO and UNICEF attempted to clarify in the early 2000s using anthropometric criteria, which they came up with by selecting a cohort of “ideal” breast-fed children recruited from all over the world to become the global standard.

What are the limitations of that norm-based anthropometric approach when it comes to malnutrition?

It is illusory. Meanwhile, other forms of malnutrition are developing. For example, overweight is a massive reality, including in countries ravaged by undernutrition. More troubling still, some publications are discussing the virtues of low-calorie diets in increasing the primate lifespan. I’m talking here about study results, published in serious journals like Nature Communications. Also, dietary standards are shifting in the direction of fertilizer- and chemical pesticide-free production. We’re beginning to see more or less solid publications in which authors assert that “eating organic” could add years of life in good health. This shows just how difficult it is to find an unchanging, universal definition for malnutrition.

Going back to the first obstacle to early treatment for malnourished children, it’s hard to eradicate something – in this case malnutrition – that is constantly reinventing itself, as social differences do; food inequality being the first among them.

So, the idea that we must eradicate malnutrition is the first obstacle to getting rid of it. What’s the second one?

Another factor slowing progress is the fact that it’s hard to get people to accept the idea that undernourished infants must be given commercial nutritional supplements whose composition meets their specific needs. Many opinion leaders who support breast feeding and family food self-sufficiency say that breast milk should be enough to cover those needs, and that any other offering will end up weakening that practice, to the food industry’s benefit. There’s a consensus on the value of breast feeding for the first six months; we are not questioning that. But in places where undernutrition is a problem, there is a need for commercial nutritional supplements for children ages six months to two or three years.

Why?

Because the deficiencies are so large that the food available on the local markets cannot remedy them. They require products designed and produced with specific amounts of vitamins, minerals, proteins, and fatty acids. The energy density of such therapeutic foods has to be adjusted to the small stomachs of very young children. Only commercial products can satisfy all those conditions.

In addition, if we expect breast milk to supply all of a child’s essential nutrients from six months to two years, a woman with five children will be breastfeeding for ten years. Is that a good fit with women’s lifestyles today? That’s not for me to answer, but I think the question is worth thinking about. I should emphasise that the advances we’ve made since the 2000s in nutrition for the treatment of severe acute malnutrition were due in large part to the fact that for once the aid organisations responded to what women were asking for. Before that, we offered them a month in the hospital with their undernourished child. That meant being away from home for several weeks, perhaps neglecting their other children – not to mention the costs of a stay in town. The vast majority of them left before the treatment was over. It wasn’t until we offered outpatient care with ready-to-use therapeutic food that a new alliance between the mothers and the clinicians was formed. And it was in that context that treatment efficacy took a quantum leap forward.

Do the economic conditions allow broad access to therapeutic food?

That is the third obstacle. I would answer that the economics never precedes the activity. We have to first create the activity to get the economics supporting it to develop. In the mid-1970s, the prices of vaccines made administering the same six antigens to all of the world’s children absolutely impossible. Similarly, when contraceptives first started to become popular, they were far too expensive for widespread use. This was also the case for antiretrovirals and many other examples. Each time, specific economic sectors had to be created to support these new public health interventions. If the economic model for combatting undernutrition continues to require that the poorest be self-sufficient in feeding their children properly, we will have failure after failure, forever. Such a feat has never been achieved – not even in the United States or Western Europe. What do they do in those places with the poorest families who can’t feed their children? They help them; they give them food and, in that way, prevent an epidemic of malnutrition.

Why don’t the countries where this phenomenon is chronic do the same thing?

No country is so poor that it has to allow its infants to die en masse. But the difference is that in Europe, the poor represent about 15% of the population, while in the poorest areas of the Sahel, for example, nearly half of families may experience poverty. Those hard-hit regions deserve a cooperative international effort, like the formula used to treat HIV, tuberculosis, and malaria, via mechanisms like the Global Fund, for example. The World Bank specifically cites combatting malnutrition as one of the actions that makes GDP growth possible. The fight against malnutrition yields general economic benefits, as did the one against HIV.

Are you hopeful that change will come?

Today, undernutrition remains the biggest risk factor for early childhood death in the world. We can envision not eliminating undernutrition, but reducing its most serious consequence. Nevertheless, as absurd as it seems, there are many, and diverse, voices questioning whether it is appropriate to feed undernourished children as early as possible to stop them from dying. The answer to that is an historical fact. While two hundred years ago every country was affected, now, two centuries later, only about thirty are left. This means that 170 of about 200 nations have managed to solve the problem thanks to well-known public policies. If it was possible in the vast majority of the earth’s countries, I don’t see why we can’t do it in the countries that still have severe problems. Being poor should no longer mean young children dying en masse while awaiting the eradication of malnutrition.