NUTRITION IN A NUTSHELL? Interview with Huub Verhagen of Medecins sans Frontieres

The Norwegian documentary film “The Famine Scam”, about the so-called famine in Niger in 2005, was awarded the Scandinavian prize for the best documentary film. This documentary basically stated that humanitarian actors like M?decins sans Fronti?res (MSF) and the media exaggerated the situation and that there was no “famine” in Niger. The image of the Norwegian Section of MSF suffered, because as Jan Egeland said, the UN Humanitarian Co-ordinator at that time, the figures he had received from MSF about the “famine” were even higher than the ones the UN had given out. We therefore met with Huub Verhagen of MSF here in Geneva in order to better understand MSF’s stance regarding malnutrition.
Q: What is your function?
I am attached to the general directorate of MSF and I cover different topics. One is to be the liaison person with Swiss civil society and official institutions on the topic of malnutrition. The Swiss section of MSF is supporting an international campaign drawing more attention to the global problem of malnutrition. We are trying to mobilize the international community to address this problem.
Q: What are your comments on the thesis that MSF has been exaggerating the “famine” of 2005 in Niger? People say that MSF did so in order to raise more funds.
The food crisis in Niger of 2005 was characterised by a major increase in the number of patients that we received in our ongoing nutritional programmes. MSF realised that food crises not only occur in acute crisis situations like conflict or natural disaster, but that they are also present in stable contexts.
This insight prompted MSF to raise media attention for this neglected crisis. And since the problem goes well beyond the Niger crisis, there is ever since a clear willingness within MSF to highlight the global problem of malnutrition as a major public health issue.
This motivation has nothing to do with raising more funds, but simply with raising awareness for a forgotten crisis that causes many unnecessary deaths, but that has been considered to be normal because we got used to a under-five-mortality rate of 200 children out of every 1’000 newborn.
In global terms, malnutrition is the underlying cause in 50% of deaths of children under the age of 5 years. That figure is a huge factor in accounting for the child deaths under the age of 5, and especially among very young children aged about 2 or 3 years. At that age, they are extremely vulnerable and depend strongly upon a proper diet to achieve healthy development. Without that proper diet, it is not only death that they are facing but their whole self-defence system breaks down with long-term consequences for their health –– even if they survive. It is a huge public health problem.
Our belief is that malnutrition has not received the attention that it deserves at the international level. This goes beyond simple humanitarian action, because malnutrition has traditionally been associated with acute conflicts and other emergencies, leading to the displacement of populations, etc.
But if you look at the actual figures, the incidence of malnutrition is extremely high even in many stable contexts.
Q: The Norwegian documentary film shows that children were not dying from malnutrition but rather from the complications of malaria. What you are saying is that malaria has nothing to do with it. People get malaria because of malnutrition?
There are different pathologies: malaria, diarrhoea, respiratory tract infections, etc. These young children are far more prone to disease because their immune system is weakened. Their immune system is weakened because they do not have a proper diet. Thus, you can correlate malnutrition with the probability of death. Then, the actual disease that makes the child die is perhaps malaria, but the underlying cause is actually malnutrition in roughly half of the cases of child mortality.
Q: I’m not a medical doctor but I don’t see the link between a mosquito bite, the development of malaria and dying of malnutrition. If I went to Africa next week and contracted malaria one way or another …
… you would not die from it. But you might die if you were malnourished and your self-defence mechanism had been weakened.
This is what researchers have been studying. Your intuition may suggest that there is no correlation between these two events. But that correlation is well established by scientific literature. Roughly, half of the child mortality rate in developing countries is a direct result of malnutrition. According to researchers, malnutrition is a topic that merits international attention. Interest in malnutrition has been neglected. That is the reason why MSF is trying to attract international attention to this problem.
You may wonder why this topic has been neglected. There are plenty of very simple reasons. For instance, students in medical schools are taught very little about malnutrition; they do learn about other pathologies, such as diarrhoea and malaria.
But there are also completely different reasons. Countries that are affected by malnutrition are humiliated because it indicates that the government is incapable of feeding its own population. As long as they do not have a solution to this problem, it is also politically difficult to make them recognize the size of the problem. This is on a completely different scale: a very political problem.
Q: Talking about malnutrition as such, and taking the example of people eating too much fast food in Europe and the United States, could one say that malnutrition exists everywhere?
Malnutrition is a clearly defined pathology, but you could say indeed that bad nutrition is typically affecting the most vulnerable, i.e. the poor in any society. What is happening in Western society is a mirror image of what is happening in developing countries. What you see is the most fragile section of the community tending to eat fast food. They cannot afford healthy food and therefore develop problems with obesity.
Q: I do accept to a certain degree what you say, but we also have lots of obesity in Norway, and I do not think it’s a problem of poverty.
Socio-cultural factors strongly affect lifestyles. But returning to malnutrition in the developing world, people do not have access to proper food because they do not have the financial resources to purchase it. People know what is good for their health. But to purchase healthy food you need money!
Roughly, what does a balanced diet mean to you personally in terms of food intake?
Q: You need vitamins, protein, minerals, milk products, meat products, etc.
Indeed. But the problem in developing countries is that fragile communities do not have access to such foods. They have to survive on a very poor cereal-based diet, which does not provide a sufficient variety of nutrients. Sources of protein, different vitamins and different minerals are essential in a balanced diet.
The subject has been studied by experts from various organisations. Roughly, there should be forty different nutrients in the diet of a child, especially after breast-feeding has been interrupted. A complement to breast-feeding should be provided from age 6 months to 24 months. This is an important period in children’s development and if they do not receive this nutrition at that time their whole development is impaired. Their immune system is weakened, making them more vulnerable to various diseases, such as malaria.
Q: I know that MSF has developed strategies to combat malnutrition.
It is probably interesting for you to understand the evolution of the way MSF combats malnutrition. In the 1970s and 1980s MSF set up small clinics and hospitals in developing countries to receive patients. Among these patients there were malnourished children. These patients were given medical treatment, but the main action was therapeutic milk to raise the nutritional status of these children.
The number of children that we treated was quite small, and the work involved very labour intensive because they were supposed to remain in hospital for several weeks. Very few mothers were able to come to these treatment centres and stay there for the three to four weeks necessary, particularly if they had other children at home. Since 2001, 2002 and 2003 there has been a kind of revolution during which a completely different strategy has been adopted. The children no longer stay in hospitals but are treated by their own mothers at home using therapeutic food. The mothers bring this food home with them from the clinic and that allows their children to regain weight.
Q: So what you are giving these children is in fact high-calorie food?
High calories with forty essential nutritional supplements. This therapeutic food is easy to prepare and does not require any medical supervision — or much less than before. These children are then checked once a week or every second week, instead of spending the whole time in hospital under supervision.
Only a few children with severe complications require hospital treatment. So the advantage of this strategy is that you can treat far more patients because you do not need to admit them to hospital. Furthermore, it does not have any impact on the rest of the family. So instead of treating hundreds of patients, we are now able to treat many thousands of them.
Q: Tell me about the different products?
There are different products for the different types of malnutrition. “Plumpy’Nut” is one that can be described as a ready-to-use therapeutic food. It is a paste based on peanuts. There are others, but this is the one mostly used by MSF and UNICEF.
There are also strategies being developed to prevent children from becoming severely debilitated in the first place, because to treat a malnourished child thoroughly is very costly.
Q: How much does it cost to treat a child with Plumpy’Nut?
For a child, it’s a between US$40 to US$60. This covers everything. The product itself is roughly half of the cost, but you also have to take into consideration the consultations and logistics.
There are other products being developed for children who are moderately undernourished, and these products are being tested. This is where the term “ready-to-use food” comes in, because some of these products are meant for communities as a whole. In this situation, we do not talk about therapeutic food but about “ready-to-use food”. This is because some of these children are not sick yet, and to avoid them becoming sick we provide them with supplements to their regular diet containing essential vitamins and minerals. They are not so much in need of the animal proteins and other elements they contain, but they really do need the vitamins and minerals.
Q: The ICRC has taken a different path. They talk about the “home-based development of nutrition”. Can you explain the difference?
This is actually the same thing. What I was just telling you about this strategy of home-based treatment implies that Plumpy’Nut, or an equivalent product, will be used by the mothers to treat their children. It’s the same thing.
Q: Wouldn’t it be better to give people more health education than to distribute this kind of food product?
The recent school of thought has been to provide health education but, at the same time, we should not assume that mothers do not know what is good for their children. They do, but they simply do not have access to the products.
You can see this very easily in all the Sahel countries. There are hunger gaps –– that’s the period before the next harvest. It is a period when there are no fresh fruit and vegetables available. Therefore, people have to survive on a pure cereal diet, and during this period you will see a strong increase in malnutrition.
You cannot uphold the thesis that, for a period of four or five months, mothers suddenly forget how to feed their children, and then after the hunger gap they suddenly remember again. We think, therefore, that the problem goes well beyond knowledge about proper feeding.
Q: Such as?
Proper nutritional intake. This means that those who are really sick, the malnourished children, are going to need therapeutic food. Ideally, the diets of all those children in all those countries where there are nutritional deficiencies need to be complemented. How to do this is, of course, remains a big question. A lot of work is being done about this at the moment. Then we are no longer talking about treating the children but rather about prevention.
Q: I know that MSF is doing a lot of lobbying in the United States Congress about this issue, and in particular for Plumpy’Nut. I have heard the figure of something close to US$750 million mentioned, if I’m not mistaken.
MSF has indeed raised awareness in the United States for the problem of malnutrition; not at the US congress though, but during a conference co-organised with the Columbia University in New York. To be clear though, we are not promoting Plumpy-Nut, but the WHO recommended community-based strategy for treating severe acute malnutrition.
If you take the figures I have given you earlier to treat one child –– i.e. US$40/60, that is the treatment itself, plus logistics, plus consultations, etc. –– you can simply multiply that by the number of severely malnourished children. Studies indicate that there are some 20 million severely malnourished children in the world. If you want to treat these children, the final figure comes close to US$1 billion. The World Bank is working on the figures to tackle malnutrition and they are including many more activities as well, like health education and dietary complements. They then come up with a figure that is ten times higher!
Q: Rather than spending US$750 million or US$1 billion to buy Plumpy’Nut, don’t you think that these same funds could be used in a better way to combat malnutrition?
Behind the problem of malnutrition there are several causes. In particular, there are acute crises –– war, displacement, etc. If we encounter malnutrition in a politically stable country, this indicates profound structural problems. For example, it has been identified in Niger that, although there was food available on the market, people did not have the money to buy it. It is as simple as that!
Instead of giving food products you can, of course, give money to the population to buy food. This is an option that Save the Children is investigating. They have some pilot projects in this sense, which seem to be promising.
In the end, what it means is that, if you have structural problems and structural causes, you must have structural answers. Development programmes need to be put in place. At the same time you cannot accept that 3 to 5 million children die every year. You are faced with a medical emergency here, and you must conduct the two approaches – development and humanitarian aid – in parallel.