Treating Global Childhood Malnutrition

 
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Beatrice Debut/MSF
Beatrice Debut/MSF

Since the beginning of April , Simon, his wife, and their six children have been sleeping under a tree in a tiny village called Noon, 25 minutes away from the Nile river by foot. They spend the night on floor mats, among the few belongings they managed to save while fleeing Melut, the town on the other side of the river. Living outside is nothing new for 41-year-old Simon; he has had to move over and over again.

Since March 2014, this Shilluk family has been on the move, fleeing fighting and ethnic tensions in Upper Nile State, South Sudan. When the conflict erupted in December 2013, Simon was living in Panyikang County, in the southern part of Upper Nile State. He was the headmaster of Dolieb Hill Combine Primary School, where 1,200 children studied.

"When the war started, my family and I had to flee," said Simon. "We left everything behind us and walked for two months. At night, we would sleep under trees. If we came across a school, we would sneak in and sleep there. We survived on food given by NGOs, some relatives, and friends we met along the way. Sometimes, I caught some fish in the river. It took us two months to reach Melut [in the far north of Upper Nile state]."

In Melut, an hour’s drive from the oil fields of Upper Nile, Simon settled in a camp called Hai Soma, populated mostly by people from the Shilluk tribe. "I spent a lot of energy building a nice tukul [a traditional hut made of grass and mud]. We were planning to stay."

His plan was cut short in early April, when clashes erupted in Upper Nile. "People were carrying guns near our camp," he says. "We feared for our lives. Everybody in the camp started to flee to the other side of the Nile, to Shilluk territory. We could not stay in the camp alone, we had to move."

In this part of Upper Nile, the river is a natural border between traditional Shilluk land and Dinka land. There are now barely any Shilluk left in Melut. The few who remain live in fear of being attacked. Simon crossed the Nile in a traditional boat after paying three South Sudanese pounds for each of his seven family members and himself.

"We took some pots and rugs with us, and that was it, it was all we could carry." They then walked to Noon and chose a tree big enough to protect them from the sun during the harsh sunny days. About 1,600 other Shilluk families are living under trees, in the same dire conditions.

"We are going to run out of food very soon," Simon said. "I don't know what we are going to do. The other problem is water. We have to walk 25 minutes to fetch water from the Nile. Old people and the blind can't go. The water is not safe for drinking. The rainy season is coming. We don't have time to build a tukul. We need some wood, plastic sheets, and ropes to build shelters before the rain starts in May. We also don’t have enough blankets."

Last week, Doctors Without Borders/Médecins Sans Frontières (MSF) distributed 25 sachets of water purifiers and 30 sachets of therapeutic food per person. These supplies should help the displaced people for about 25 days, before the next distribution takes place.

Simon is now working as a community health worker for MSF. But he wishes he could go back to his beloved job. "I miss teaching. I miss my colleagues. Some are dead, some are soldiers."

Life has taken a different turn than he expected. For now, Noon is his home but he cannot say about tomorrow, when he and his family might have to move once again.

MSF
MSF

Starting in February 2014, Doctors Without Borders/Médecins Sans Frontières (MSF) has been providing medical assistance to more than 30,000 South Sudanese refugees who fled their homes and sought sanctuary in Sudan’s White Nile state. Most came from Upper Nile state, which borders Sudan to the southeast, part of the large population of South Sudanese who’ve been displaced from their homes, fearing for their lives, since conflict erupted in their homeland in December 2013.

Working with Sudan’s Ministry of Health, MSF is providing medical care and nutritional support to refugees in White Nile State. To date, teams have conducted more than 36,174 consultations and vaccinated 2,333 children under 5 years old for polio and 8,566 children under 15 for measles (following a positive diagnosis). This preventive care approach has helped curb disease outbreaks in the area.

“Most of those arriving are women, children and the elderly,” says Dr. Amir Osman, MSF medical team leader in White Nile State. “They are coming on foot or by public transport. Since some of them are in poor health and nutritional condition, we are conducting medical consultations and nutritional screening on arrival. Severely malnourished children are immediately enrolled into the therapeutic feeding program, while supplementary food is provided for those moderately malnourished.”

Currently, there are 3,230 people enrolled in MSF’s therapeutic feeding program. They receive regular medical check-ups and supplementary food, particular attention is paid to malnourished pregnant and lactating women. Thus far, MSF has conducted 2,111 antenatal care consultations and assisted 152 safe deliveries.

Most of those in White Nile come from the towns of Waddakona, Kaka, Al-Renk, Malakal. All left due to insecurity. Some managed to salvage a few of their possessions while others left with nothing. “I walked for three days from Waddakona, Upper Nile State to North Kweik, in Sudan, where I had to sell my cows, sheep and goats to get money for other necessities,” says one woman. “I used to be a government employee and self-dependent, now I’m in another country and dependent on aid.”

Most people entered Sudan through the western area of the Nile and settled around Um Jalala, an area commonly known as “Kilo 10.” They’ve since been relocated to three transitional areas, namely Jorai, El Kashafa and El Rades. Others entered from the eastern side of the Nile settled in an area called Al-Alagaya.

These areas are near the Nile, which facilitates water transportation, which is crucial during the rainy season when roads become impassable and only boats can be used to transport patients with complicated medical cases to hospitals in Kosti. In the El Kashafa area, MSF has constructed a 20-bed clinic to be able to respond rapidly to critical cases while using mobile clinics to reach those in the two other transitional areas in the vicinity.

The medical needs of the population are apparent; on average, MSF conducts some 4,300 consultations per month and refers about 15 cases to Kosti. Moreover, living conditions are very congested, with six or seven people living in Tukuls (huts) meant for three or fewer. The congestion increases the spread of communicable diseases—respiratory tract disease, in particular—one of the main illnesses that MSF teams in White Nile are treating. To prevent the spread of communicable diseases and diseases associated with water, hygiene and sanitation, MSF has identified groups of community health workers to carry out health education activities.

Heavy rains have likely prevented some people from coming into Sudan, as most people cannot cross the river when it floods. However, whenever renewed violence erupts in parts of South Sudan bordering Sudan, numbers automatically go up. Despite the border that divides them, the commonalities and mutual relations between those arriving and the host communities have allowed the two populations to coexist peacefully.

Mali  Aurelie Baumel/MSF
Mali Aurelie Baumel/MSF

Your support of MSF helps fund projects like our medical-nutritional program in the West African nation of Mali, which is one of the poorest countries in the world and a place where one in five children do not reach their fifth birthday.  In 2013, MSF teams in Mali treated over 7,200 severely malnourished children, supported the care of 83,000 children with other illnesses at public health clinics, and hospitalized 5,300 children with serious illnesses in MSF’s pediatric unit.

Nutritional and Medical Treatment:

In 2014, MSF teams—made up of 12 international staff and about 252 locally-hired staff—are running the program, in collaboration with the Malian Ministry of Health, at five public health centers and the district hospital in Koutiala.  Severely malnourished children are treated as outpatients unless they have other illnesses.  The children requiring hospitalization are transferred to Koutiala hospital where MSF runs a 300-bed pediatric unit that includes an in-patient therapeutic feeding center for severely malnourished children with complications and a pediatric ward for other sick children.  The remaining children are treated entirely as outpatients at five outpatient feeding centers located at public health centers in Koutiala and Konséguéla, the largest rural health zone in Koutiala district. 

Children with malaria, pneumonia, diarrhea, and other illnesses are treated at the health centers unless they require hospitalization.  The health centers are trained to refer severe cases of any of these illnesses to the hospital where MSF’s pediatric ward is located.  This year, MSF logisticians are building permanent facilities for the pediatric ward, replacing the temporary structures on the grounds of the hospital.  The new structure will provide 205 beds and will be completed by the end of the year.   The team is also working to implement a system of early detection of pediatric complications, increase training of hospital staff, and reorganize the supervision structure in the pediatric department to improve the quality of care.  MSF will also expand its activities at the hospital to include neonatal care.

Malaria Prevention:

Malaria, a parasitic disease transmitted by mosquitoes, is still the leading cause of child mortality in Mali and one of the main reasons for hospitalization of malnourished children.  This year, MSF is running its third and final year of its malaria prevention pilot program in the Koutiala district.  The 2014 program is targeting the entire population of 170,000 children between three months and five years of age in the Koutiala District and helping them stay healthy during the three-month malaria season. 

Early Intervention:

MSF is expanding its successful pilot project that promotes early intervention activities to help children lead healthier lives.  This project incorporates prevention into a comprehensive health care program targeting the main causes of child mortality. 

Initially implemented in Konséguela from 2010-2013, the program is being rolled out to the entire district from 2014-2017 in partnership with the Malian Ministry of Health.  This program is designed to offer a complete package of free preventative care for every child that starts soon after birth and continues until they reach age two.  Teams vaccinate all infants and children under age two according to the approved vaccination calendar in Mali, including new additions of PCV 13 (pneumonia closely follows malaria as the second leading killer of children in Mali) and rotavirus vaccine once approved by the Ministry of Health.  Healthy infants and toddlers will be examined at regularly scheduled “well baby check-ups” with their growth closely monitored.  These children will also receive SMC, insecticide-treatedmosquito nets to help prevent malaria transmission, and highly nutritiousfood supplements to prevent malnutrition. 

Participation in the early intervention program has been extremely high in Konséguela and has had excellent results: the prevalence of severe acute malnutrition was reduced by 69 percent among 12-23-month-olds (1.7% vs. 5.4% in the rest of Koutiala District), stunting was reduced by 34 percent at age two, and 97.2% of children had received all vaccinations at age two (compared with 50% in Koutiala). We expect to achieve similar results in other parts of Koutiala District. 

By expanding early intervention activities to the entire district, MSF seeks to save more children’s lives while demonstrating that preventative care can be implemented effectively and affordably on a large scale in a resource-poor rural area like Koutiala district.

MSF/Nick Owen
MSF/Nick Owen

Before the conflict that erupted in South Sudan in mid-December 2013, Doctors Without Borders/Médecins Sans Frontières (MSF) would typically have around 200 children in its ambulatory therapeutic feeding center (ATFC) at any one time, said Grace Ayuelu, MSF medical team leader in Leer. Ayuelu has been working in Leer hospital for almost a year.

“But now, we have over 1,800 children,” she said. “That is a big number.”  

During the conflict, many people’s houses in Leer, as well as the MSF hospital, were looted and razed to the ground. People fled into the bush for safety, many of them going months without anything to eat other than wild roots and whatever else could be gathered from the land.

People are now starting to return to Leer, and the partially destroyed MSF hospital is up and running again, although at half its previous capacity. Now, the busiest area of MSF’s Leer hospital is the ATFC, where children under five are seen and their level of nutrition assessed.  

There are over 207 MSF staff from South Sudan and beyond currently working in Leer, providing emergency nutrition and outpatient care to the population. The MSF project in Leer also accounts for two other ambulatory therapeutic feeding centers in southern Unity state, one in Nyal and another in Mayendit.

Before its hospital was destroyed at the end of January, MSF had been working in Leer for the past 25 years, providing both in- and out-patient care for children and adults, surgery, maternity, HIV/TB treatment, and intensive care. The hospital was the only fully functioning secondary facility in all of southern Unity State, serving 270,000 people.

Ramon Pereiro/MSF
Ramon Pereiro/MSF

Côme Niyomgabo, a 40-year-old Burundian, has finished his nine-month mission coordinating the Médecins Sans Frontières (MSF) project to reduce child mortality in Bouza, in the Tahoua region in Niger. Here he shares his experience with us.

What is the situation like in Bouza at present?
We have just lived through the most difficult time of the year: the hunger gap (food shortage period) and a high prevalence of malaria due to the rainy season. The time interval between June and October is in fact a critical period for young children. Since the beginning of November, the number of children being admitted has decreased: the most difficult period is about to end. However, it is a chronic crisis coming back year after year after year, which is the reason why we are already getting ready for the next peak. Based on our experience, we know that anticipation is an important factor; we need a well-trained team ready to intervene. Precisely in Bouza, a very rural area, the lack of qualified human resources poses a real challenge, as does access to health facilities. Villages are often remote and during the rainy season roads are usually impractical.

What are the main activities carried out in the project in the past few months?
Two of the main causes of child mortality in Niger are malaria and malnutrition. During the most critical months, we have tried to make high-quality treatment available to sick children at the earliest possible time. In Bouza, the health system depends on health posts called cases de santé, where there is a health agent whose medical training is very basic; then there are integrated health centres suffering from a chronic scarcity of qualified nursing staff, and then the district hospital located in Bouza town. In 2013, in many places, MSF carried out a programme known as PECADOM, consisting of getting as close as possible to the patient using simplified tools to diagnose and treat malaria as well as other childhood diseases. Furthermore, ‘malaria agents’ were trained to work in remote villages and cases de santé were reinforced. This should help to detect early malaria cases, treat simple cases and refer the complicated ones.

We have also started seasonal malaria chemoprevention, consisting of giving children between 3 months and 5 years medication once a month to prevent malaria. This is spread over the four months where malaria transmission is at its highest, from July to October. The children concerned are much more likely not to develop malaria or to develop a milder form of the disease. This strategy has been well received by the population. The number of children treated has increased from one round to another; the next ones will visibly spread across the most remote villages. Today, when we discuss it with the population in each area, people confirm that the number of cases as well as the number of admissions have decreased.

How does MSF involve the community in the project?
We carry out a lot of awareness-raising activities amongst the community. Our teams work with 140 volunteers in the villages who convey messages about malnutrition, malaria, what to do when a child is sick, etc. The role of these volunteers is very important to gain access to the population and to spread the messages.

We have also defined a strategy known as mamans lumière (mother light), addressed to children at risk of contracting severe acute malnutrition. The mothers of these children become part of a group of mothers trained by MSF, who explain to them how to prepare the food so as to make the most of it and thus cover their children’s nutritional needs. Mothers bring their own foods, cook them together and then feed their children. This strategy involves the community in malnutrition prevention and treatment, integrating respect for their community and culture. Different decision-makers, traditional or religious leaders also collaborate in community mobilisation activities.

Can you summarise your experience in Bouza through an image or a story?

When we really try and make the effort we can make a difference changing things for the better, and in a very fast way. Seeing children arrive seriously ill due to malnutrition or other pathologies and later witnessing their rapid recovery and watching them smile at their mothers… that is probably the most deeply ingrained image that I will most likely keep of my experience here.

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Project Leader

Kat Read

New York, NY United States

Where is this project located?

Map of Treating Global Childhood Malnutrition