07 May 2012

Severe Acute Malnutrition: Neglect Upon Neglect? Or an Opportunity to Mobilise Communities Against Malnutrition Writ Large?

2 May 2012 – UN NEWS CENTRE.  “At least one million children are at risk of dying of malnutrition in the central-western part of Africa’s Sahel region due to a drought crisis, the United Nations Children’s Fund said today, adding that more resources are urgently needed to help those in need. ‘We estimate that in 2012 there will be over a million children suffering from severe acute malnutrition – what’s important to know is that malnutrition can kill,’ UNICEF’s Director of Emergency Programmes, Louis-Georges Arsenault, said in a news release.”

It is ironic that this most media-visible form of malnutrition (severe acute malnutrition or SAM) is also the most under-researched form.  Don’t get me wrong, there is a lot we know:

  • SAM is when a child's weight for height is more than 3 standard deviations below median WHO growth curves (by way of comparison, moderate malnutrition is between 2 and 3 standard deviations below the WHO curves) OR mid upper arm circumference (thinness of arm) less that 115m (about 4 inches) OR severe oedema (excessive build up of fluids)
  • SAM affects 20 million children worldwide (about 180 million suffer from moderate + acute malnutrition), usually as a consequence of famine or armed conflict
  • Children with severe wasting (SAM) are twice as likely to die as kids with moderate wasting
  • Conventional treatment of SAM has been on an inpatient basis (recovery and rehabilitation), followed by discharge and follow up
  • Given sufficient resources this model works well in reducing mortality, but of course SAM is unlikely to occur in places that have good health facilities
  • So Community Management of Acute Malnutrition (CMAM) has become the new conventional wisdom.
  • CMAM is (a) early detection of SAM in a community setting, (b) nutritional treatment with ready-to-use therapeutic food (RUTF) and (c) medical treatment in a clinic for the most serious cases
  • RUTF has increased the effectiveness of CMAM quite significantly (it is an oil based nutrient dense paste which requires no refrigeration and simple packaging), but its use makes many countries nervous (especially India) as it is seen as a potential Trojan Horse for food industry influence
  • Expert and systematic reviews conclude that while there is limited experimental evidence of CMAM’s effectiveness and cost effectiveness (Bachmann, Picot) there is substantial body of non-experimental evidence that it can achieve outcomes as good as those at inpatient clinics, but at much lower cost (at about 1/5th of the cost per person treated).
  • The cost of CMAM in terms of per disability adjusted life year (DALY) averted is estimated to be $42-493 in Malawi and $50 in Zambia. These numbers compare favourably with the costs of purchasing DALYs through other proven health interventions such as salt iodisation and iron fortification.          

There are a number of unanswered research questions:

What types of CMAM are best for each context? The evaluations so far have tended to be versus inpatient treatment, but what about different governance/incentives around different types of CMAM?

How sustainable is CMAM? Can it be embedded successfully in existing health systems? Do CMAM resources get captured by the most powerful community players?

Can RUTF be produced at lower cost, with greater local acceptance, but the same or enhanced efficacy? What public guidelines are needed to ensure businesses act in the public good?

What intervention methods are most effective for children less than 6 months of age? There is no evidence.

Finally, can CMAM be a mechanism for sensitizing communities and politicians to the less visible chronic forms of malnutrition? Or will it draw attention from the more widespread, still devastating, but less dramatic forms of malnutrition?

Is SAM the most neglected manifestation of the neglected issue of malnutrition? And might CMAM be an entry point for making all forms of malnutrition harder to neglect?

The technical issues here are critical, but the strategic and political ones are equally vital.

Recommended Reading and Links


Lawrence Haddad said...

One of my regular correspondents has made 3 good points (my comments after each point)

1. Not sure about my point that SAM is caused by famine and conflict .. 40% of global total of SAM cases are in India – but caused not by sudden food shocks but chronic lack of access to appropriate foods, sanitation etc etc. Madhya Pradesh gets close to Sudan’s prevalence levels (12% compared to 16%) and way higher than Ethiopia and other traditional homes of high numbers of SAM cases.

(LH: You are right-India is an obvious and major counterpoint--I should have said often caused by famine and armed conflict, as Bachmann says in his review)

2. Don't children with SAM have a 10x higher chance of death than non-malnourished children ?

(LH: Children who are severely wasted are 9 times more likely to die than a child who is not wasted. I was comparing severely wasted vs moderately wasted)

3. Still huge resistance in India to any private RUTF product – leading to the situation that RUTF is being made for export (by CIPLA, by Nutriset - with ingredients from MP)

(LH: why no public-private partnerships?)

Thanks for the comments!

Marie said...

For infants < 6 months, I'd go further to say there was little hard evidence on interventions, but lots of 'dabbling' (see MAMI Review, http://www.ennonline.net/pool/files/ife/mami-project-summary-report-final-041209.pdf) despite a considerable burden of SAM in this age group - a longstanding blind spot in SAM programming.

Gastric Ulcer Omeprazole for Horses said...

In community-based therapeutic care, all patients with SAM without complications are treated as outpatients. This approach promises to be a successful and cost-effective treatment strategy.

Unknown said...

It would be sad not for the children if their food will be replaced with a food that is called with an abbreviation. I still like indian food perth back home.

Shirley Dunn said...

Everyone of us should be concern with this issue. In remote areas, there is really an existing poverty where malnutrition especially on children is happening.

Roy Jones said...

It is mistakenly conceived by some communities that the malnutrition is a problem primarily of the government. Education as well as advocacy campaigns are in effect in schools worldwide. This is again reiterated in health care facilities when pregnant women submit themselves for pre-natal examination. It is a wonder that with the availability of these free resources, there are still uneducated masses as to the effects and triggers of malnutrition.

Monet Green said...

Shirley is right, but we must not only be concerned about the lack of immediate medical clinics but as well as how we take care of the people we care. There are extreme sports enthusiast that take the liberty to create clinics near the place they use to play around.

Darlene Nugent said...

How would Africa conquer this long battle against malnutrition? I hope many government organizations and NGOs would care to fund CMAM to stop this prolonged agony of African kids.