A nutrition program is a bit different than other medical programs in that the patients don’t necessarily feel sick. They may not even feel hungry if there is something in their belly, nourishing or not. So, in many cases we have to go find them. We have teams of Community Health Workers who comb through the villages every day, visiting each house. They round up all the children under 5 years old, poke and prod a bit, pinch their skin and watch it rebound. Most importantly, they do the MUAC test: the Mid-Upper-Arm-Circumference test. Apparently all kids under 5 should have roughly the same arm circumference and if it is less than 114mm, they fall into the “severely malnourished” category and are entered into our program. 114mm is about the circumference of an empty toilet paper roll.
Most children will be in our ATFC – the ambulatory therapeutic feeding program. Each week they come to one of our mobile clinics where they are measured and weighed, vaccinated if necessary, given vitamin A, checked for malaria, and fed a hearty helping of Plumpy Nut – the high-energy, protein-rich, fortified, peanut-based power paste. The mother is then given a week’s supply of Plumpy Nut and they head back home.
There are often complications that, for whatever reason, end with the child not recovering. MSF has devised several creative solutions to mitigate them. A “protection ration” is additional food given to the mother at each visit, intended for the family. This is to ensure that the Plumpy Nut rations intended for the malnourished child are not shared among the other children. A “discharge ration” is when a bag of grain is given to the family once their child is discharged from the program to ensure the child doesn’t relapse into a state of malnutrition after leaving the program. These additional food supplements also help to motivate the mothers to keep coming each week and not to default, despite the long distances they have to walk in the scorching sun, the fields that need to be tended, the housework that needs to be done and the other children that need to be cared for. On the flip side, they also provide enough of an incentive to NOT keep the child in the program intentionally so as to keep receiving free Plumpy Nut. Unfortunately, there are rumors that sometimes one child in the family is deliberately underfed so as to stay in the program and keep receiving free food. Understandable for a mom struggling to feed all her kids.
There is also the problem of mothers selling their weekly supply of Plumpy Nut in the local market, and so MSF makes them bring back all the empty wrappers the following week to prove they didn’t sell it. Unless of course they sell it to a conspiring neighbor….
Apart from these social complications, there are of course medical complications. Malaria is a big one. These children are admitted into the ITFC – the intensive therapeutic feeding program. They are essentially hospitalized and treated for their medical condition as well as their malnourishment. Once the medical condition is taken care of, they go to the ATFC.
When the child reaches a certain weight and is no longer in the “severely malnourished” category, they are discharged from our program. Unfortunately, they still often fall in the “moderately malnourished” category. That, however, is a whole other can of worms that MSF does not usually address directly. Rather, MSF would lobby other organizations, such as the World Food Program or Unicef, to do broader food distribution. According to our nutrition expert, sometimes it happens; sometimes it happens too little too late; sometimes it doesn’t happen.
As the person brought in to install an incinerator in the health centres and hospitals that house our feeding programs, I can hardly comment on what works, what doesn’t, or what MSF should or shouldn’t be doing for malnutrition. Let alone what other organizations should or shouldn’t be doing. I am left just to wonder about it all, grateful for that cherished afternoon dunk in the Nutella jar.