Information dated 01.01.2001 Malnutrition definition and MSF treatment "When I arrived in early July the MSF logistician I had come to relieve gave me a warning: "Here, everything smells of death." - MSF logistician, Southern Sudan, 1998 When a person cannot take in sufficient nutrients to meet their needs, the body begins to waste away. First they lose fat, and then muscle. Once a child has fallen below 80% of the weight that is average for their height they are defined as malnourished. Malnutrition is usually one of the five major causes of death in any emergency situation. The others are diarrhoea, malaria, measles and pneumonia. Young children are more vulnerable to malnutrition than adults. There are several reasons for this. Children are growing quickly, so their relative needs for nutrients are greater. Also, they are incapable of ingesting bulky meals - they need small frequent feeds, and mothers may not be able to provide these during an emergency situation. And children are more prone to infectious diseases, which cut the appetite and also use up extra calories and other nutrients. When malnutrition affects an entire population, including older children and adults, the situation is called a famine. Fighting a famine There are very few situations today in which a famine can be considered a purely "natural" disaster. Drought, flood and other environmental factors can of course lead to food shortage, but there are almost always human forces at work as well - such as war, forced displacement of populations, or sabotage of agriculture by the use of land mines. Helping a population survive a famine thus requires far more than simply setting up feeding centres for malnourished children. The causes of the situation must be addressed, as the same things that caused the famine in the first place will also be working to hamper the relief operation. The role of MSF is one of advocacy - which means that we use our international contacts and credibility in order to try to convince governments, rebel groups and organisations to allow free access of humanitarian aid to the affected civilian population. This does not always work, however. The political obstacles are often the most difficult to overcome. Even now, when the world has the technology and resources to ensure that no person need ever go hungry, the spectre of famine still haunts many war-affected countries. Once access to the affected population has been negotiated, the first priority is to ensure an adequate general food distribution. Usually, the minimum energy requirement of a population is an average of 2,100 kilocalories per person per day. This means about 600 grams of food per person per day. For a population of 100,000 people, the logistics of a food aid operation must therefore be up to providing 1,800 tonnes of food each month. In good conditions this may be possible, but if trucks are in short supply, or if rains have washed out bridges, or if warfare makes roads too dangerous to use, a life-threatening food shortage can easily occur. In most emergency situations it is one of the United Nations agencies, usually the World Food Programme (WFP), that is responsible for the general food distribution. A typical ration comprises a carbohydrate staple (such as rice or maize), a source of protein (such as lentils or kidney beans), and on oil, to give a concentrated source of calories. Ideally, small quantities of salt and sugar are also given, to improve palatability. MSF recommends that families should also be given a blended food, being a mixture of various flours and milk powder, which are useful for making a nutritious porridge for small children. How malnutrition kills The most common form of malnutrition, called marasmus, results in an affected child being severely wasted, with no fat and very little muscle tissue left on his or her body. The internal organs, including the heart and the blood, are also weakened. The child is left with no reserves to fight infection, and any illness that comes along is likely to be fatal. The commonest causes of death during a famine are in fact infectious diseases, rather than starvation per se. Chief among these are pneumonia, diarrhoea, and measles. The other form of malnutrition, called kwashiorkor, in which the child's body is swollen, likewise kills by lowering resistance to infection. However, kwashiorkor can also be fatal in its own right, because of the disturbed levels of salts and minerals (electrolyte imbalances) that accompany it. In a therapeutic feeding centre, where only severely malnourished children are cared for, many deaths tend to occur at night. This is because these children are especially prone to low blood sugar (hypoglycaemia) and low body temperature (hypothermia). Preventing malnutrition and famine Food is a complex issue. In the majority of wars, food is used as a weapon. It is of course the civilian population that suffers, rather than the enemy soldiers. The role of MSF in preventing famine is thus one of advocacy - doing what we can to argue on behalf of stricken communities, alerting the world to their plight, attempting to take them out of the firing line. Even at the level of an individual child, malnutrition is rarely a simple consequence of inadequate food. Infectious diseases play a major role. With a bout of diarrhoea, for example, a child loses its appetite and then weight; this puts him or her more at risk to another infection, which further weakens the body and causes loss of weight. This cycle of infections quickly leads to malnutrition. MSF health projects attempt to break this cycle by providing basic health care to all members of a community. Children need to be fully immunised and to have access to curative care when they fall sick with infections. Health and nutrition education of mothers is an important element. An example - Famine in Southern Sudan In mid-1998, famine hit the Bahr-el-Ghazal region of Southern Sudan. In fact, it had been a long time coming, and was the culmination of two successive years of poor harvests, due to drought and flood, as well as the drawn-out war between the North and the South. The international movement of MSF already had teams in the region, and these were massively reinforced. The activities we launched included: setting up therapeutic feeding centres for the severely malnourished; providing medical care in the affected areas; providing supplementary feeding for at-risk people; performing nutrition surveys in order to monitor the situation and to have sound information to use for advocacy purposes; engaging in advocacy with the organisations responsible for general food distribution, to try ensure that it was sufficient to prevent more people becoming malnourished; calling publicly for an indefinite prolongation of the cease-fire between the Government and rebel forces. This objectives of this advocacy were to allow humanitarian aid to continue and, just as importantly, to allow hundreds of thousands of displaced people to return home and tend to their crops so as to avoid a repetition of the famine during the following year. How MSF teams treat malnourished children Children found to be less than 70% of the expected weight for their height are defined as severely malnourished. MSF teams admit them to a therapeutic feeding centre, where they receive intensive care. First of all, any infections are treated - the commonest being pneumonia, diarrhoea and malaria. As the children are usually dehyrated (lacking in fluids) they are given oral rehydration solution. At the same time gentle re-feeding is commenced. MSF teams use a standard recipe to make up high-energy milk. This is a blend of milk, oil and sugar. It contains high numbers of calories in a small volume of food, which is what malnourished children need. In the first week they must be fed up to 12 times per 24 hours, and the feeding centres are staffed day and night. Because these children are at such high risk of death they are checked each day by an MSF doctor or nurse for life-threatening infections. They are also immunised against measles, and given a preventive dose of vitamin A, which prevents a blinding condition known as xerophthalmia. They are also de-wormed and given other vitamins and minerals. In a well-run feeding centre the severely malnourished children should gain weight quickly. Within a month they should be up to 80% or more of their expected weight and ready for discharge into the supplementary feeding programme, in which they will be given take-home dry rations. If MSF teams can get to them early enough, 95% of severely malnourished children can be saved from what would otherwise be certain death. The main constraints to our achieving this outcome in all situations are logistical and political. These are discussed in Fighting a Famine.