Op-ed by Dr Susan Shepherd, an American paediatrician, examining how breast-feeding, a healthy diet and malaria prevention have made positive gains on the state of malnutrition in Niger.
Running your infant to the paediatrician for a well-baby check up and shots may seem like just another chore. Who do you know who ever had measles? Many parents wonder if all those shots are really necessary in the first place. But last week, mothers, nurses and doctors in Niger reminded me just how powerful and important these simple gestures are.
I'm just back from Madarounfa, the southern-most district in central Niger where Médecins Sans Frontières/Doctors Without Borders (MSF) has worked for more than a decade. Yes we still treat too many malnourished children and care for those ill with malaria or other common illnesses. But there's a new thing going on.
Nutritional support
Thousands of mothers and infants cheerfully come to the health centre every month for weight checks, immunization updates, and, once the baby reaches six months of age, to receive nutritious baby food as a complement to breastfeeding. As mosquito nets are distributed to the newborns, nurses and mothers engage in lively exchange about how to care for a sick baby and how to feed children so they stay well.
A malnourished child rests in the ICU unit of the MSF hospital in Guidan Roumdji. The combination between malaria and malnutrition is deadly as the child becomes more vulnerable and weakened, and both malaria and malnutrition cause anemia. © Tanya Bindra
Niger is a land-locked country that straddles the Sahara Desert and the savannah just to the south, known as the Sahel.
For most Nigeriens, daily life presents many challenges and struggles. The country has been through three food emergencies in the past six years, and this in a country where the vast majority of its 16 million people work the land to make a living.
In 2010, almost half the country's population received some type of short term economic support in the form of food distribution or cash transfer and this year the same help is going to about one quarter of all Nigeriens.
Child survival
But among all this hardship, Nigerien politicians and health professionals are making remarkable progress in child survival. Despite being ranked near the bottom of the U.N. Development Index, child mortality rates in Niger are in free-fall and dropping twice as fast as its bigger, wealthier neighbour Nigeria.
Even with serious economic woes, child malnutrition rates are actually improving. This flies directly in the face of the conventional wisdom that suggests improvement in health indicators only follows economic growth.
So what is happening in Niger? In 1990, Niger had the highest child mortality rate in the world. By the end of the decade, the government started to promote vaccination campaigns along with vitamin A distributions. Between 1998 and 2005 the percent of children under five who had received a dose of vitamin A went from seven percent to 75 percent and the percentage of children vaccinated against measles doubled. Certainly a positive step, but then 2005 happened.
Child mortality
In March of 2005 waves of malnourished and sick children, in numbers never before seen, started flowing through the doors of the MSF hospitals in the south central region of the country. No one understood exactly what was going on, but at that moment there was only time to react.
A hospital worker is overwhelmed by the number of patients that come through the hospital in Guidan Roumdji each day. © Tanya Bindra
The Ministry of Health quickly approved a national nutrition protocol, UNICEF mobilised, and scores of non-governmental organisations came into the country, employed many skilled Nigerien doctors and nurses and set to work treating malnourished children by the tens of thousands. By the end of the year, nearly 100,000 children were helped – 60,000 in MSF programmes alone. It was, at the time, the largest ever emergency response to severe acute malnutrition.
As it happens many times following crises, a number of very positive changes emerged. Since 2005, more children have been treated for malnutrition in Niger – estimates of over one million – than anywhere else in the world. In other words, children in Niger have a better chance of receiving the treatment they need than in any other country in Africa or Asia where malnutrition takes the highest toll.
Malnutrition and malaria
The Ministry of Health has also conducted at least one health and nutrition survey of children under five every year. Epidemiologic monitoring is simply an indispensable component of any health system. The survey conducted in June 2010 sounded the alarm that prompted major changes to nutrition programming that year and set precedent; for the last three years, a large portion of children under two receive nutritional support with novel enhanced nutritional foods during the months preceding the harvest.
Studies from an MSF programme showed that mortality rates were cut in half when children received quality food supplement tailored to their needs in a programme with a high level of adherence and acceptability.
Dr Diallo Aboubacar, the medical doctor in charge of the Integrated Health Centre (CSI), visits patients waiting for their first phase of malnutrition and malaria treatment. © Tanya Bindra
Nutrition and health are inextricably linked: children are more prone to sickness and death if they are malnourished, and vice versa. Malaria in Niger, for example, is a major cause of illness and death, so it is unthinkable to treat children for malnutrition without simultaneously checking for malaria, or distributing insecticide-treated bed nets.
Free health care
Since 2005 the number of cases of malaria treated in children under five has more than tripled; in 2009 reaching more than 1.5 million treated with appropriate medications. Expansion on this scale was possible because national politicians decided that health care must be provided free of charge for children under five and the Global Fund aided with supply of drugs. The percentage of families who have bed nets to sleep under has gone from zero to 75 percent since 2005.
And last but not least, vaccinations. Since 2005, the percentage of two-year-olds who have received their complete set of vaccinations has doubled. There is still a ways to go - and children in Niger don't yet benefit from all the protections that immunization provides to children in more developed nations – but this is definitely progress.
Much of this progress was set in motion via decisions made by Nigerien leaders; some of it was accelerated by humanitarian actors and Nigerien health professionals working on the ground. This conglomerate of governmental and emergency aid organisations has laid the groundwork for revitalising this most important activity: well-baby visits.
Integrating nutrition and health
Breast-feeding, a healthy diet and treatment for acute malnutrition, completed immunisations, malaria protection and treatment, and good data collection are the backbone of this success. These are the basics of the ‘moon-shot’ moment Dr Mickey Chopra, Chief of Health at UNICEF, described in a recent interview, referring to the 47 percent drop in child mortality in Niger over the last 10 years.
A nurse distributes the therapeutic milk formula, F75, which comprises the first phase of malnourishment stabilisation. © Tanya Bindra
Yet all this really isn't rocket science. The hard part is figuring out how to keep the system working, because this progress is fragile. While enabled by good policy, a lot of the health gains can be traced to investments by emergency aid organisations, whose funding is neither stable nor predictable.
The next critical phase will be integrating the connection between nutrition and health into public health systems and reaching children earlier with interventions that work. It should be about improving children's health as much as an emergency response.
Scaling Up Nutrition
Here in lies the challenge for the Scaling Up Nutrition (SUN) initiative which aims to curb under-nutrition worldwide and whose members met last week at the United Nations in New York.
Nigerien mothers and health professionals have done a lot to show this new SUN movement what is possible. Now the question for the SUN is what it can do to help consolidate and accelerate these gains in contexts like Niger's. It certainly starts by recognising how providing nutritionally enhanced supplements to treat and protect children from malnutrition coupled with essential health services are among the most effective interventions that can be rolled out.
If Nigerien leaders and the numerous international and national non-governmental actors are up to the task, who knows how fast this child survival epidemic can pick up speed.
Dr Susan Shepherd is a paediatrician from Butte, Montana. She has worked for Médecins Sans Frontières/Doctors Without Borders (MSF) for the last six years and coordinates work in nutrition. She has worked in Uganda, Chad, Niger, Kenya, South Sudan, Burkina Faso, and Ghana.
This article originally appeared in the Huffington Post (US)