Using Niger as an example, this text seeks to explore the dilemmas involved in medical responses to child malnutrition when such malnutrition is endemic (strong, permanent presence) and gives rise to seasonal peaks (epidemics) each year. It is this form of malnutrition that continues to have a major impact on mortality in nearly 40 countries, where a phenomenon persists that once was common to all of humanity but that has gradually disappeared over the past two centuries in four out of five countries.

Since 2005, the most recent year in which Niger was identified as having a food and nutrition crisis, efforts have largely focused on treating severe acute malnutrition - the serious marasmus of a skeletal child whom the most minor complication (usually an infection) can kill. Progress has been impressive in this area: home treatment of severe cases with a new generation of therapeutic foods led to a sharp increase in the number of cases treated during the 2005 crisis (from several thousand to tens of thousands) and an unprecedented cure rate. These results rank Niger among the leading countries fighting malnutrition. But waiting to intervene until the disease's last stage does not achieve the same results as an earlier intervention. If, as anticipated in this year's action plan, 340,000 severely malnourished children are treated and, optimistically speaking, the mortality rate is limited to 4%, the number of deaths would still reach 11,000.

Furthermore, restricting the distribution of a therapeutic food to cases of serious marasmus poses other problems, especially in places where malnutrition is already highly endemic and where a major seasonal peak magnifies the phenomenon every year. While treating these severe cases in the home rather than in hospitals is given priority, we must not forget that about one child in six presents complications requiring a hospital stay. When incidence is high during the annual seasonal peak, the number of hospitalisations quickly becomes unmanageable for health care centres and hospitals. Late treatment of frequent and fatal malnutrition means condemning ourselves to overcrowding at feeding centres. In such conditions, qualified medical personnel cannot concentrate on the most complicated cases, which have the highest risk of death.

Ending the rationing of food supplements

To avoid an excessive number of severe cases and partially reduce hospitalisation costs, it would be preferable to avoid limiting treatment only to severe acute cases of malnutrition and to distribute a food supplement at a less advanced stage of nutritional deficiencies.

A pilot project was conducted in 2006 and 2007 in Guidam Roumji district in Maradi province. In 2006, the results demonstrated that using triage (measuring height, weight, etc.) to differentiate cases of moderate acute malnutrition from other cases is so cumbersome that it alone monopolises a large share of the available resources. All that remains is one-third of the budget for purchasing food for children.

The option of no longer using anthropometric measurements to select patients (weight, size, brachial circumference), but instead treating all children in the age group most at risk, was implemented in the same district in 2007. This effort has resulted in a more balanced distribution of costs, two-thirds of which can then be devoted to purchasing food for children. Both operating methods have had the same impact on reducing the anticipated number of severe cases. But treating the entire age group is better relative to Niger's epidemiological data. In a population of children, a large proportion of acute malnutrition cases indicates the existence of nearly ubiquitous nutritional deficiencies.

Despite a body of scientific and experimental evidence, however, early treatment of malnutrition does not have the consensus it needs to become a common and ongoing practice. As a result, the lack of sufficient pilot projects demonstrating the efficacy of this approach could lead to abandoning a practice whose funding cannot be guaranteed after the few one-off operations have ended.
In spite of this difficult situation, Niger's innovative approach again stands out on the world stage. In 2010, the administration and humanitarian organisations set a goal of distributing food aid to some 500,000 children before they reached the stage of acute severe malnutrition.

A review of the planned operation raises several issues about the conditions necessary for ensuring the success of such an initiative. The first concern is biological in nature: young children's rapidly growing bodies require a food supplement that meets all of their needs and that is distributed during the entire period when the risk of death and permanent sequelae is at its peak. Available epidemiological data indicate that the 6-24-month age group is the prime target. The second issue is social. The plan to distribute aid to a specific group does not guarantee that it will be carried out. The first stage involves creating a consistent list of beneficiaries and setting an initial health objective. Distribution must then comply with the established list. Lastly, the food supplement must be consumed by the distribution's target beneficiary rather than by another person - a family member, for example. The last issue is economic. The economic model underlying the programme must cover all costs related to the key factors necessary for successful outcomes throughout the expected duration of the programme.

Covering all of an infant's nutritional needs

For the time being, the product selected by the World Food Programme (WFP) for temporary distributions lasting several months is a mixture of micronutrient-enriched flower, CSB Plus, which does not cover the requirements for animal proteins essential for the healthy growth of children this age.

UNICEF would have preferred a food covering all of an infant's nutritional needs. In order to move in this direction, MSF proposed several months ago providing a food product adapted for some 200,000 children. The idea is to supplement the distribution of flour, which has demonstrated its effectiveness for the other family members during periods of scarcity. In fact, the crucial interest of the product's quality is the absence of milk, which is too expensive, both for families and the institutions fighting malnutrition.

The lack of an adequate economic model for current programmes weakens the food supplement's quality and limits the amount of time children can receive it. The change in political regime and persistent food problems, which grew even worse in 2010, have created an opportunity to try new ways of combating malnutrition in early childhood. Proposed responses to malnutrition, which previously held no interest for a regime coming to the end of its term, can now be discussed. Organisations have become strongly tempted to seize this opportunity. Yet we must not forget that it is necessary to meticulously prepare for and carry out mass distributions if we are to achieve positive public health outcomes. Public health initiatives that fail are often based on solid arguments from a biomedical perspective, but are viewed quite differently by the supposed beneficiaries due to social and cultural factors. Moreover, when dealing with a highly charged issue, success cannot be dictated by fiat but must be proven with epidemiological data that organisations must take sufficient time to gather. The lack of serious scientific evidence will only embolden the sceptics and deprive many children of nutrients essential to their growth and sometimes even their survival.