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
- Steve Collins et. al. 2006. Lancet (pdf). This is a seminal review from the guru
- Bachmann 2010. Expert Reviews (pdf). On cost-effectiveness of CMAM + the Zambia study
- Wilford et. al. 2011. Health Policy and Planning—Malawi case study (pdf)
- Gera 2010. Indian Pediatrics (pdf). A global review with thoughts on applicability to India (hardly any studies there despite high levels of SAM)
- Picot. 2012. Systematic Review of all SAM treatments, but no cost data (pdf).