Jean-Hervé Bradol

Undernutrition, which can range from individual cases to nutritional crises affecting an entire population, is one of the most frequently encountered pathologies in humanitarian medicine. Doctors have many patients in clinics and are pressed for time. Clinical skills are scarce and follow-up examinations rare. Diagnosis is performed chiefly through anthropometrics, in other words, when a patient’s body measurements (weight, height, upper arm circumference) and age are known, they can be compared with reference tables to assess the extent to which the patient deviates from an ideal growth norm. The use of such a norm does not mean that the aim is to have each individual attain an ideal stature at a given age. Georges Canguilhem, in his book The Normal and the Pathological, explains the meaning to be attributed to a norm: “Strictly speaking a norm does not exist, it plays its role which is to devalue existence by allowing its correction. To say that perfect health does not exist is clearly to say that the concept of health is not one of an existence, but of a norm whose function and value is to be brought into contact with existence in order to stimulate modification. This does not mean that health is an empty concept.”G. Canguilhem, The Normal and the Pathological, trans. C. Fawcett, Zone Books, New York, 1991, p. 77. In the case of undernutrition, the desired modification or correction of existence is to prolong the life of the individual, and it has in fact been firmly established that serious deviations from the anthropometric norm are associated with high mortality rates among young children. The norm currently in use was revised by the World Health Organisation in 2006. Without dwelling on this point, we should note that the new anthropometric charts make it easier to identify children whose lives are at risk. Specifically, what we need to do is reduce the mortality rates in populations in which 10%, 15% and sometimes up to 20% of children do not reach the age of five. The weak response of national governments and international organisations makes such an action all the more important for a humanitarian medical organisation. To take just one example, available estimates show that 90% of children suffering from the most lethal form of undernutrition (severe acute malnutrition) receive no treatment whatsoever.

More than 90% of all cases of infant and young child malnutrition occur in 36 countries. The countries most affected are those where MSF is already present for other reasons. There are certain justified reservations concerning the aggregation of the data and the analyses based on these data, but where undernutrition is concerned, epidemiological data at least are based on national surveys using common case definitions and methodology. The continents most affected are Asia, particularly the Indian sub-continent, and Africa, particularly sub-Saharan Africa. Available estimates show that two-thirds of all cases are found in rural areas. In the current state of knowledge, action is recommended before the age of 2 or 3. The majority of deaths occur at this age, while at a later stage in life, unaddressed dietary deficiencies have permanent effects on the individual, including diminished learning capability and higher frequency of degenerative diseases in adulthood (cardiovascular pathologies, diabetes). Moreover, rapid but late (after early childhood) correction of underweight status is thought to increase the risk of chronic disease in adulthood. So if medical intervention is to be effective rather than harmful, it must be undertaken during early childhood. When a medical visit reveals wasting or stunting, in most cases neither the family nor the medical practitioner can provide the foods needed for the child’s nutritional recovery, despite the lethal consequences. These foods are either not commercially available or too expensive for the great majority of households. When an entire region suffers from malnutrition, the situation will inevitably worsen in almost exactly the same way each year at the same time during the period just before the harvest, known as the hunger gap or hunger season, when families have exhausted their economic reserves and must wait for the income from the coming harvest. Undernutrition then gives rise to a seasonal epidemic outbreak that accentuates the already considerable dietary deficiencies of the population, to the point where this causes a peak of mortality. This is a critical season, as it also sees an increase in infectious diseases such as malaria, diarrhoeal diseases and respiratory infections. Undernutrition weakens the child’s immune defences and thus leads to infections, which in turn further degrade the child’s nutritional situation. The two pathologies together produce a surge in infant and child mortality. However, whereas it is accepted that infections should be treated, this is less true where dietary deficiencies are concerned. No healthcare team would let an infant go without treatment in the case of a malaria episode, serious respiratory infection or diarrhoea, but the vast majority of undernourished infants leave the consultation without a prescription to treat their dietary deficiencies, despite the fact that the medical literature, depending on the source, considers undernutrition to be the cause of 35% to 53% of all deaths of under 5-year-olds. In contrast to the chronic situations discussed above, food relief and nutritional care have made the most progress in recent decades in the most extreme circumstances: war and natural disaster. The problem is that the majority of undernutrition-related deaths occur not in these exceptional situations, but in the everyday circumstances of regions where three factors combine to produce these chronic disasters: food shortages in many families; ignorance of the feeding practices suited to the physiological needs of infants; and the strong effect of infectious disease. To help reduce mortality, the treatment of malnutrition should be included in paediatric procedures which are particularly aimed at preventing and treating infections.

SCIENTIFIC AND TECHNOLOGICAL PROGRESS THROUGH TRIAL AND ERROR IN THEIR IMPLEMENTATION IN THE FIELD

The development of medical knowledge has given us a better understanding of whom to treat in priority (pregnant women and very young children), why they should be treated (to reduce the mortality rate), and also how they should be treated. The links between a number of daily ration ingredients (vitamins, minerals, amino acids, etc.) and certain pathological conditions are better understood today. The new generation of nutrition products is more effective because it covers not only the individual’s calorie and protein requirements but also includes some 40 micronutrients. Ready-to-use therapeutic foods have also proven to be essential for outpatient treatment in cases of severe acute malnutrition. In Angola in 2002, MSF was able to treat about 8,000 cases of severe acute malnutrition in just a few months. It is now possible to provide care for tens of thousands of children, with unprecedented cure percentages, often above 80% (Niger, 2005). These new interventions are successful not only because of the improved composition of therapeutic foods but also, and especially, because such products at last respond to mothers’ requests to treat children at home in the simplest manner possible. The increase in the number of children treated and in the proportion of cures is largely due to the fact that the treatment is not administered in medical facilities. Doctors have made an about-face in their views on the role of mothers, and of the family in general. Previously, it was believed that mothers were failing to feed their children properly and resisting the constraints of the old treatment protocol. When the child’s condition became critical, they often refused to spend more than one month with him/her in hospital. Mothers gave legitimate reasons for refusing hospitalisation, such as the need to look after their other children and the costs to the family of a hospital stay – including direct costs (payment of at best a portion of the hospital costs) and indirect costs (income lost because the mother is looking after the child full-time). Today, they can treat children successfully at home, on condition that medical institutions make therapeutic foods available to them. These products not only meet the specific needs of a rapidly growing organism, they are also suited to family circumstances, i.e. to the time and resources available to families to feed the youngest children. They require no particular preparation, and their doughy consistency makes them easy for the youngest family members to eat. At the same time, the means of fighting infections have improved, with new vaccines and drugs. All these advances in nutrition and infectiology could bring a quantum leap in the effectiveness of paediatric care, on condition that the children in the most vulnerable situations benefit from them.

Although the scientific and technical advances are real including new norms allowing more accurate selection of the children at greatest risk, more effective treatments and opportunities for earlier intervention, they are used only to a limited extent in the field. Nutrition specialists today agree to the promotion of breastfeeding, the dissemination of information on the specific nutritional requirements of the mother and infant, the enrichment of certain industrial food products (e.g. iodine in table salt), the massive distribution of certain micro-nutrients (e.g. vitamin A) and the treatment of severe acute malnutrition. Restricting the distribution of a therapeutic food to serious cases of wasting has several disadvantages in areas where endemic undernutrition is compounded by a sharp seasonal peak each year. There are too many severe cases for public health institutions to treat, and they are too dispersed within the population to be easily identified, since this requires a complex, costly and permanent screening process covering all children. Outpatient treatment is preferable, but about a quarter of all cases display complications that require hospitalisation. When the rate of incidence is high - during the annual peak - the number of hospitalisations soon becomes unmanageable for health centres and hospitals. If therapeutic food is also distributed in cases of moderate acute malnutrition to prevent the occurrence of too many severe cases thus reducing the number of hospitalisations (as was done at Guidam Roumji, Niger, in 2006), the screening needed to identify the cases requiring treatment involves so much work that the process alone swallows up a high proportion of the available resources, leaving only one-third of the budget for the purchase of therapeutic foods. In 2007, the option of treating all children in the age group at greatest risk (6-36 months), without screening, was tried out in the Guidam Roumji region. This allows a more balanced share of financial resources, since two-thirds of the budget is used to buy food for the children. These two approaches, implemented in successive years in the Guidam Roumji region of Niger (2006 and 2007), had the same impact in terms of reducing the number of severe cases. Treating the entire age group is consistent with the epidemiological data: high prevalence of acute malnutrition cases within a given population of children indicates that nearly the entire population is affected by dietary deficiencies, in one form or another. The problem is that distributing a nutritional supplement to all children from 6 months to 3 years old during the critical period of the year entails a total expenditure on specialised foods that no public health budget can afford. Ready-to-use specialised foods cost about €2.5 a kilo, and half is spent on the raw materials: milk, sugar, groundnuts and oil. Whether the treatment is administered early and spread over several months, or late and concentrated in a period of about a month during an outbreak of severe acute malnutrition, it requires about 10 kilos, or €25. These foods are too expensive for large segments of the population, and the price is incompatible with both national health budgets and international aid budgets.

Apart from cases of severe malnutrition, the standard practice until now has been to give children cereal paps. But these paps do not meet international nutritional recommendations for infants because they lack protein of animal origin which is essential for growth. A new generation of paps enriched with milk and micronutrients has recently been developed, but when all the parameters involved in their use are taken into account, these new paps do not offer a less expensive alternative to ready-to-use nutritive pastes. In 2006, the United Nations’ World Food Programme distributed 6.7 million tonnes of food aid, of which infant paps accounted for only 7% and products containing milk only 0.3%. Such paps are in fact mainly used for schoolchildren rather than infants. Even though the latter account for the great majority of deaths due to underfeeding, they are poorly served by international food aid.

THE POLICY OF RATIONING AND INVISIBILITY

While it is now accepted that the previous generation of paps does not meet the needs of the youngest children, there is still debate over the proposal to treat infants with the new generation of foods before they are diagnosed with the most severe form of malnutrition. Apart from war and natural disaster situations, this proposal faces the usual hostility to food distribution and the lack of agreement among experts on the ideal composition of foods to treat non-severe forms of acute malnutrition. Donors are providing tens of millions of dollars in new funding to support research aimed at developing a new family of food supplements.

Is the available scientific information insufficient to enable carers to take the decision to treat malnutrition before it becomes severe? Although the nutrition situation is still bad in one in five countries, we should not forget that the other four have resolved a problem that, less than two centuries ago, affected the entire world. Apart from Europe and North America, there are many success stories in Asia and Latin America (e.g. Mexico and Thailand). Research projects in progress should not be a prerequisite for taking action. In fact, the purpose of scheduled clinical trialsInternational Lipid-Based Nutrient Supplements (iLiNS) Project Overview, 12 April 2009. The iLiNS Project is supported in part by a grant from the Bill and Melinda Gates Foundation to the University of California, Davis. The University of Malawi, the University of Tampere (Finland), the University of Ghana, the Institut de Recherche en Sciences de la Santé (Burkina Faso), Nutriset (France), Project Peanut Butter (Malawi) and Helen Keller International are also participating in the iLiNS Project. is not to find the food that would best meet the physiological needs of children but to “assess the effectiveness of low-cost formulations of lipid-based nutrient supplementsThe terms “lipid nutrient supplements” and “ready- to-use food supplements” designate the same category of products. (LNS) for infants and young children”. The clinical trial protocol mentioned above divides children randomly into six groups. The goal is to compare the impact of six different treatments for nutritional recovery, and in particular to compare their cost. Two of the six groups will receive no milk and one will receive no food supplements for one year, even though the available data on the nutritional deficiency of the Malawian children taking part in the clinical trial and prior studies conducted in the same country indicate that depriving certain groups of milk is unadvisable. The main purpose of such research protocols, in which MSF sometimes participates, is not to specify the ideal composition of food supplements for children’s growth; rather, it is to cut expenditure while hoping to retain some effectiveness. The protocols study the effects of reducing the number of beneficiary children, reducing daily amounts (by steps of 10 grams in this example) and lowering quality by reducing the proportion of milk or eliminating it entirely. The drafting of such clinical trial protocols is governed by economics - namely a policy of rationing - rather than by the need to consider established scientific fact. This approach would be more understandable if the food supplements included raw materials that were in short supply instead of merely milk, sugar and oil.

Could malnutrition be treated without industrial food supplements? Experiments in which aid is distributed in the form of money rather than food products indicate that families’ food consumption improves, but that no significant improvement occurs in the anthropometric indicators for young children. The dietary deficiencies that cause undernutrition are so diverse and so pronounced that it is often impossible to compensate for them through the foods available in the family’s immediate environment. There is intense controversy among experts on the degree of responsibility attributable to each of the factors that contribute to undernutrition. The debate is clearer, however, when it concerns the choice of solutions rather than the search for causes, and in the countries which still have a high incidence of early childhood undernutrition, programmes to fight this problem are therefore primarily governed by economic considerations. The main concern is therefore to distribute as little food as possible to infants while retaining some degree of effectiveness. The clinical trial projects described above clearly indicate that the supply of nutritional supplements is limited primarily by the cost of the ingredients. In current market conditions, neither families nor public health institutions can afford to procure foods that can offset all dietary deficiencies. As a result, the annual cycle of nutritional disasters in regions with high rates of infant and child undernutrition cannot be broken without a change in the cost of specific foods for young children. Today, the United States Department of Agriculturehttp://www.fns.usda.gov/fsp/ affirms: “We help more than 35 million people to put healthy food on the table each month.” Food autonomy for the poorest is thus not guaranteed in any country, but the solution adopted in the United States (public food aid for over 10% of the population) is harder to apply in parts of the world where 50% of households do not have enough income to feed themselves properly. Instead of being offered food aid, poor families in the South are advised to improve their eating habits and to increase their incomes by taking part in economic development.

Experts and donor countries currently agree that the distribution of foods suitable for the nutritional recovery of young children should be restricted to cases of severe acute malnutrition. From a medical standpoint, withholding treatment until a patient reaches the worst stage of undernutrition is not advisable. From the standpoint of public health, this leads to restrictions on the share of spending allocated to purchasing food for children, in favour of the budget used to pay the wages of staff members who constantly screen the child population to identify severe cases. Lastly, analysis of the political aspect of the experiment shows that, in the eyes of political leaders (in Nigeria, Niger and Ethiopia, among others), treatment of severe acute malnutrition has the disadvantage of having large groups of emaciated children arriving at health centres. The resulting media attention causes strong tension between the authorities, the press and the organisations providing nutritional care. Dissemination of information on a country’s inability to feed its people undoubtedly damages its reputation and discourages investors. From the standpoint of domestic politics, images of emaciated children call into question the leaders’ ability to ensure the survival of part of the population. The memory of governments overthrown as a result of food crises remains sharp and clear in the minds of the political leaders of the countries affected. For this reason, political elites often give in to the temptation to forbid (as in the northern states of Nigeria) or limit (as in Niger and Ethiopia) the treatment of malnutrition. In truth, the public health recommendation to treat cases of severe acute malnutrition is both a step forward and a medical and political aberration. Never, in recent times, have so many children been successfully treated. But although these children account for under 10% of the total number of severe acute malnutrition cases worldwide, they are still numerous enough to attract media attention that is worrying for governments and too numerous to be sustainably covered by the public health institutions of the countries that are making an effort to treat them.

Many of the countries concerned by this problem do not make it a national priority to treat infant and child malnutrition. In contrast, the international community placed the fight against world hunger first in the Millennium Development Goals adopted by the United Nations. The goal of improving access to food for a billion individuals is part of the effort to reduce severe forms of poverty. To catch the attention of countries and international organisations, any health policy proposal must affirm that a limited initial effort will, in the long term, eliminate the problem and thus ensure a maximum return on investment. From a rhetorical point of view, the Millennium Development Goals meet this criterion. In the case of world hunger, economic development is presented as the sole means of eliminating food shortages, whereas food aid is accused of helping to prolong under-development. Despite a great deal of research proving the contrary, political discourse often persists in describing food shortages as crises of under-production. In terms of solutions, the emphasis is placed on economic growth - particularly increased production through scientific and technical progress - and on the promotion of healthy eating. On 13 September 2006, the director-general of the United Nations Food and Agriculture Organisation (FAO), Jacques Diouf, issued an appeal for a “second Green Revolution” in the hope of “helping to build a world without hunger”. In this productivist reasoning, mere treatment of malnourished individuals is not perceived as an end in itself. On the contrary, it is viewed as a bottomless pit swallowing up ever-increasing amounts of funding that do not help to eliminate the cause of the problem.

Instead of being an integral part of the effort to eradicate a cause of morbidity, curative care in the public health policies of low-income countries is in most cases restricted to the treatment of a small number of cases (in our example, the severe forms of acute malnutrition). According to the time-honoured argument, priority should be given to treating the causes (lack of schooling and economic underdevelopment) rather than the consequences (undernourished children). To keep the fight against infant and child malnutrition from falling into a rut, it must be given a more modest objective than the disappearance of world poverty and hunger, namely, reducing the number of deaths due to undernutrition. The fight against child malnutrition involves more than mere distribution of specialised food aid to families lacking the purchasing power to buy specific nutritional supplements for young children. History indicates that other factors – such as education, social mobilisation, economic development and scientific progress – probably play a more decisive role. It is necessary to understand, however, that when wasting and stunting are already established, a number of biological constraints make it essential to have industrial foods suitable for young children. When undernutrition is not yet present, the feeding of young children can still be based on an intelligent combination of the foodstuffs available in the family’s immediate environment, on condition that the family has the required purchasing power. But the massive use of industrial foods for infants in rich countries suggests that the image of a mother wholly devoted to the child’s welfare and perfectly capable of managing food issues in a given environment does not correspond to social reality. This observation in no way calls into question the importance of breastfeeding, which is one of the keys to healthy growth, but breastfeeding alone cannot meet the need for foods of animal origin up to the age of 2 to 3.

The industrial aspect of the solution considered often encounters hostility from activists (the Right to Food movement in India, for example), who see it as the Trojan horse of agri-food multinationals. Yet experience shows that the increased consumption of the new generation of therapeutic foods has instead spurred the growth of small and medium-sized firms using local raw materials (in the Dominican Republic, Malawi, Niger, Ethiopia, Democratic Republic of Congo, etc.). Large multinational corporations have taken no initiatives in this field. For this productive sector to develop, demand has to increase, but demand is stifled today by the high cost of the raw materials and the low purchasing power of many families. The most difficult step in stopping the rationing of these specialised foods, and making them abundant in the 30 countries that account for 90% of cases of infant and child malnutrition, is to persuade the countries concerned and international donors to provide several billion dollars per year on an international scale, mainly to cover the cost of raw materials. This would be a public health action requiring as much political will as the launch of the expanded immunisation programmes in the early 1980s when the prices of vaccines were reduced by a factor of 20. Lacking a new economic model for the production and distribution of foods for young children, doctors will have to resign themselves to diagnosing wasting and stunting, without, in the great majority of cases, being able to do anything about it. A high proportion of the world’s children will continue to be denied access to the foods that are indispensable to their survival.