Severe acute malnutrition during emergencies: Burden, management, and gaps
Paluku Bahwere Abstract
Introduction
Natural and man-made disasters, including floods, droughts, earthquakes, and armed conflicts, create nutrition crises. Unfortunately, the frequency and severity of such disasters have been increasing since the beginning of the 20th century, and their contribution to the burden of acute malnutrition is increasing every year. However, their contribution to the burden of acute malnutrition is underrecognized due to the ways in which global statistics are built and causes of death are reported. Fortunately, the success of the current protocol for treatment of severe acute malnutrition (SAM) and the integrated approach to treatment has created a momentum allowing expanded coverage of treatment of SAM, especially in humanitarian emergency contexts. For this progress to be maintained and accelerated, changes in nutrition information systems at the national and global levels are needed, and the persisting barriers to the expansion and integration of treatment of SAM into routine health systems need to be removed. Emergency funding approaches and objectives have to include sustaining and amplifying the achievements of the short-term palliative interventions. Nutrition programs implemented in emergency contexts have the capacity to contribute to answering priority research questions, and this capacity should be more optimally utilized.
Natural and man-made disasters, including floods, droughts, earthquakes, and armed conflicts, share common characteristics regarding the nutrition situation of affected communities and individuals [1, 2]. In all of these situations, food production and the harvesting of farm produce are disrupted, while access to food from the market is limited by security threats, reduced household income, and the collapse of food distribution and marketing networks. At the same time, food preparation practices and food safety are compromised in a context in which healthcare and sanitation services have collapsed [3]. Such disruption to normal life results in an increased vulnerability to food insecurity and to malnutrition, with the ability to cope depending on the type and severity of the disaster and the gender and age of those affected. Thus, nutritionrelated interventions, including food aid and treatment of severe acute malnutrition (SAM), have rightly been historically part of the first-line emergency response, in addition to the provision of shelter, sanitary facilities, and clean drinking water [2]. Several publications have reported the nutritional impact of emergencies on the prevalence of acute malnutrition and the contribution of acute malnutrition to morbidity and mortality among emergency-affected communities [4–10]. A number of organizations and activists, however, are strongly lobbying against investment of resources in the treatment of SAM and are advocating for a concentration of resources solely for preventive interventions aiming at addressing the determinants of malnutrition by improving habitual diets and child-feeding practices, and reducing exposures to illnesses and food insecurity [11, 12]. This campaign is going on despite the continuous increase in the number of emergencies and the steady increase in the number of displaced people and refugees since the 1970s [13]. The first purpose of this paper is to demonstrate that SAM remains an important public health concern and will remain so for many decades to come if the current trend of increasing frequency
Key words: Burden of severe acute malnutrition, disasters, humanitarian emergencies, nutrition information systems
The author is affiliated with Valid International, Oxford, UK. Please direct queries to the author: Paluku Bahwere, Fond Tasnier, 6, 1332 Genval, Belgium; e-mail: [email protected].
Food and Nutrition Bulletin, vol. 35, no. 2 © 2014 (supplement), The Nevin Scrimshaw International Nutrition Foundation.
S47
S48
of disasters persists. A second purpose is to highlight some issues that distort the reality regarding the burden of SAM. A third purpose is to emphasize the need to use emergency programs of community-based management of acute malnutrition (CMAM) to answer pending research questions.
The increasing frequency and intensity of natural and man-made disasters Regardless of the definition of disasters used, all available statistics from the Centre for Research on the Epidemiology of Disasters and the Centre for Systemic Peace have consistently observed an increase in the frequency and intensity of disasters, especially of natural and man-made disasters. The number of natural disaster events recorded rose from about 100 per decade up to 1940, to nearly 2,800 per decade during the 1990s. After a period of steady decline in the number of armed conflicts in the world, the downward trend has ended and the number of ongoing armed conflicts has been around 32 from 2010 to 2012 [13]. This increase in the number and scale of crises and emergencies over the past decade, as well as the long-lasting nature of most armed conflicts, has resulted in huge population displacement. Since the end of the Cold War in 1991, 30 to 50 million refugees or internally displaced people (IDP) have been recorded annually [13].
Contribution of emergencies to the burden of SAM It is well recognized that the increasing frequency and intensity of natural and man-made disasters is fueling the global prevalence rates of SAM. A review of surveys of acute malnutrition established that between 1988 and 1995, the prevalence of acute malnutrition among children under 5 years of age in internally displaced and conflict-affected populations ranged from 11.7% to 81%, with a median prevalence of 31% [8]. A study of Kurdish refugees from Iraq demonstrated that the increase in prevalence of acute malnutrition occurs very fast during the first weeks of an emergency [4]. The study showed that within 1 month of the onset of the crisis, children under 2 years of age sustained significant weight loss, and the prevalence of acute malnutrition was threefold the normal range in children aged 12 to 24 months [4]. Also, during the first 2 months of the crisis, 12% of infants died, including the great majority of those who developed acute malnutrition, and this situation distorted the picture of acute malnutrition, giving a false impression of no impact of the crisis on infant nutrition status [4]. Statistics currently used to inform policy are obtained mainly by compiling the national data from
P. Bahwere
the UNICEF-supported Multiple Cluster Indicator Surveys and the USAID-supported Demographic and Health Surveys. Caseloads from emergencies, especially from new and acute emergencies, are not included [14]. There is no regular compilation of statistics on SAM among IDP and refugees, and thus it is currently difficult to provide an exact figure for the yearly contribution of emergencies to the SAM burden. A rough calculation using the United Nations High Commissioner for Refugees (UNHCR) figure of 6.5 million new IDP or refugees in 2012, of which 17% were children under 5 years of age, and assuming a prevalence of SAM of 31%, leads to an estimation of 1.1 million cases of SAM from new emergencies not included in the 2012 global estimates of SAM burden. UNICEF figures, which indicate that its humanitarian programs provided treatment of SAM to 2.11 million children in 2012, confirm the high caseload from emergencies [15]. This huge contribution of emergencies to the global SAM burden means that SAM will remain a public health concern, even if preventive interventions are successful in eradicating SAM in stable conditions. To have a good representation of this contribution, systems such as the refugee nutrition information system have to be improved and reorganized to allow good estimation and forecast of the contribution of emergencies to the SAM burden. Review of mortality data during recent humanitarian crises in Africa (table 1) reported under-five mortality 3.6- to 60-fold the baseline rates [9, 16]. Abundant literature has demonstrated that SAM is a major contributor to this mortality [4, 9, 10, 17–19]. As in nonemergency contexts, the contribution of SAM to mortality occurring during emergencies is not sufficiently highlighted in global statistics because of the way the international system for collection of data on cause of death is organized [20]. Although it is already possible to code malnutrition as cause of death using codes E40 to E46 of the ICD-10 (International Statistical Classification of Diseases and Related Health Problems 10th Revision), as did Sacarlal and colleagues for their review of mortality in Mozambique [21, 22], this is not yet common practice, and the ICD-10 system and guidelines still favor the selection of infections complicating SAM as the primary cause of death. However, despite the limitation when attention is paid to these codes, SAM ranks high among the leading causes of death in children. In the Mozambique review, SAM, with 2.1 deaths per 1,000 child-years, was the third leading cause of death among children aged 1 to 4 years after malaria (6.1 deaths per 1,000 child-years) and diarrheal diseases (2.3 deaths per 1,000 child-years) [21]. Some authors have avoided the underestimation of malnutrition as a cause of death by systematically attributing an infectious and a nutritional cause to each death [23]. This approach, which is in line with the philosophy of the Integrated Management of Neonatal and Childhood Illness, has the advantage of reflecting
S49
Severe acute malnutrition during emergencies
TABLE 1. Relative mortality in African famines or recent complex emergencies
Country Somalia Sudan Malawi Ethiopia Ethiopia Kenya Somalia DR Congo Southern Sudan Ethiopia
Survey year
Baseline mortality (deaths/10,000 days)
1980 1986 1986 1989 1991 1992 1992 1994 1998 2000
0.6 0.6 0.5 0.6 0.6 0.6 0.6 0.5 0.6 0.6
Observed mortality Ratio of observed (deaths/10,000 to baseline days) mortality 11.3 10.1 1.8 2.4 5.0 7.4 17.0 30.0 20.0 3.2
18.6 16.8 3.6 4.0 8.3 12.3 28.3 60.0 33.3 5.3
Source: adapted from Toole and Waldman [9], Salama et al. [16].
more accurately the burden of both the infectious diseases and SAM, and should be tested on a larger scale.
Improving coverage of emergency response CMAM has been part of the package in almost all the emergency responses, and this approach is allowing the humanitarian community to cost-effectively cope with the number of cases of SAM during emergencies while meeting the minimum recognized SPHERE quality standards [24–26]. Importantly, the good performances observed during the phase of CMAM field experimentation on 23,511 children with SAM treated between 2001 and 2005 have been maintained, despite rapid geographic scaling up [27]. However, as mentioned above, the unmet need remains huge, and efforts are needed to break the persisting barriers, such as ideological resistance to investment in treatment of SAM by some nutritionists and organizations, the unproductive debate about the type of food to be used, insufficient understanding of the principles and benefits of treatment of SAM among many policy makers, and the scarcity of health personnel skilled in the management of SAM. Also, every single enabling factor and opportunity should be used to ensure that SAM receives due attention. For example, efforts should be made to ensure that the current emphasis on and prioritization of tackling stunting does not reduce resources dedicated to the tackling of acute malnutrition. Usually it is emergency events that create the momentum for getting acute malnutrition onto governments’ agenda and on the list of top priorities for ministries of health [28]. Indeed, in many countries the integration of the management of SAM into routine services and its countrywide scaling up occurred as a result of the momentum created by an emergency, and benefited from emergency funding [29]. Unfortunately, too often the funding for the management of SAM
vanishes after the emergency has ended, as many key decision makers, including government officials, academics, and donors, are still looking at acute malnutrition as a short-term emergency concern. This limits the capacity of many emergency-prone countries to sustain the capacity for management of SAM and for a timely response to subsequent emergencies. This leads to many lost lives at the beginning of an emergency. This situation can be avoided if attention is given during an emergency to ensure integration of management of SAM into routine services and inclusion of SAM in all national nutrition strategy and policy documents. For this to happen, donors should not restrict the use of emergency funding to short-term palliative interventions.
Emergencies as an opportunity for research All of the early research on the effectiveness of CMAM was carried out in emergency contexts [24, 30]. Recently, studies testing the efficacy or effectiveness of specialized food products or different approaches for preventing or treating moderate acute malnutrition (MAM) have also been successfully conducted in emergency contexts [31, 32]. Emergency programs, however, and especially those addressing the needs of IDP or refugees residing in camps, are not yet sufficiently used for addressing research questions, despite the potential they offer. Protracted crises offer the possibility for research related to CMAM with minimal confounding factors, and can offer an environment allowing efficacy trials that are difficult to achieve in other communitybased studies. Confounding factors can be minimized, for example, in studies examining such questions as the most appropriate and cost-effective food for treatment of MAM or SAM, the long-term impact of treatment of SAM, the role of antibiotics in children with uncomplicated SAM, and the appropriate timing of starting
S50
antiretroviral therapy in children with SAM and HIV infection.
Conclusions The current trend of increased frequency and severity of natural and man-made disasters suggests that special efforts are needed to capture accurately the contribution of emergencies and development contexts to the
P. Bahwere
burden of acute malnutrition in global statistics in order to accurately estimate the resources and efforts needed in the fight against malnutrition and to ensure that due attention is given to SAM now and in the future. Because there is still some uncertainty regarding some aspects of the current protocols for management of SAM, it is paramount for the humanitarian community to support research within their emergency programs, given the opportunity that some of these offer for research.
References 1. Bhatia R, Thorne-Lyman A. Food aid in emergencies and public health nutrition. Forum Nutr 2003;56:391–4. 2. Toole MJ. Mass population displacement. A global public health challenge. Infect Dis Clin North Am 1995; 9:353–66. 3. Loretti A. Armed conflicts, health and health services in Africa. An epidemiological framework of reference. Med Confl Surviv 1997;13:219–28. 4. Yip R, Sharp TW. Acute malnutrition and high childhood mortality related to diarrhea. Lessons from the 1991 Kurdish refugee crisis. JAMA 1993;270:587–90. 5. Chotard S, Mason JB, Oliphant NP, Mebrahtu S, Hailey P. Fluctuations in wasting in vulnerable child populations in the Greater Horn of Africa. Food Nutr Bull 2010; 31:S219–33. 6. Mason JB, Chotard S, Cercone E, Dieterich M, Oliphant NP, Mebrahtu S, Hailey P. Identifying priorities for emergency intervention from child wasting and mortality estimates in vulnerable areas of the Horn of Africa. Food Nutr Bull 2010;31:S234–47. 7. Moore PS, Marfin AA, Quenemoen LE, Gessner BD, Ayub YS, Miller DS, Sullivan KM, Toole MJ. Mortality rates in displaced and resident populations of central Somalia during 1992 famine. Lancet 1993;341:935–8. 8. Toole MJ, Waldman RJ. Refugees and displaced persons. War, hunger, and public health. JAMA 1993;270:600–5. 9. Toole MJ, Waldman RJ. The public health aspects of complex emergencies and refugee situations. Annu Rev Public Health 1997;18:283–312. 10. Orach CG. Morbidity and mortality amongst southern Sudanese in Koboko refugee camps, Arua District, Uganda. East Afr Med J 1999;76:195–9. 11. Bergeron G, Castleman T. Program responses to acute and chronic malnutrition: Divergences and convergences. Adv Nutr 2012;3:242–9. 12. The Madrid High Level Consultation on Hunger, Food Security and Nutrition: In the Post-2015 Development Framework, 4 April 2013. Available at: http://www.fao .org/fsnforum/post2015/sites/post2015/files/files/ Background_and_Agenda_HLM_on_FSN.pdf. Accessed 23 March 2014. 13. Marshall MG, Cole BR. Global report 2011: Conflict, governance, and state fragility. Vienna, Va, USA: Center for Systemic Peace, 2011. Available at: http://www .systemicpeace.org/GlobalReport2011.pdf. Accessed 23 March 2014. 14. UNICEF-WHO-The World Bank. 2011 Joint child
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malnutrition estimates—Levels and trends. Available at: http://www.who.int/nutgrowthdb/estimates/en/. Accessed 23 March 2014. Iyer A. Humanitarian action and post-crisis recovery: Analysis of achievements and challenges. Available at: http://www.unicef.org/parmo/files/Thematic_Briefing _Humanitarian.pdf. Accessed 23 March 2014. Salama P, Spiegel P, Talley L, Waldman R. Lessons learned from complex emergencies over past decade. Lancet 2004;364:1801–13. Mason JB, White JM, Heron L, Carter J, Wilkinson C, Spiegel P. Child acute malnutrition and mortality in populations affected by displacement in the Horn of Africa, 1997–2009. Int J Environ Res Public Health 2012; 9:791–806. Moss WJ, Ramakrishnan M, Storms D, Henderson SA, Weiss WM, Lejnev I, Muhe L. Child health in complex emergencies. Bull World Health Organ 2006;84:58–64. Sapir DG. Natural and man-made disasters: The vulnerability of women-headed households and children without families. World Health Stat Q 1993;46:227–33. Centers for Disease Control and Prevention. Famineaffected, refugee, and displaced populations: Recommendations for public health issues. MMWR Recomm Rep 1992;41:1–76. Sacarlal J, Nhacolo AQ, Sigauque B, Nhalungo DA, Abacassamo F, Sacoor CN, Aide P, Machevo S, Nhampossa T, Macete EV, Bassat Q, David C, Bardají A, Letang E, Saúte F, Aponte JJ, Thompson R, Alonso PL. A 10 year study of the cause of death in children under 15 years in Manhica, Mozambique. BMC Public Health 2009;9:67. World Health Organization. International statistical classification of diseases and related health problems 10th revision. Available at: at:http://apps.who.int/ classifications/icd10/browse/2010/en. Accessed 23 March 2014. Hennart P, Mudjene O, Balegamire B, De Vos D, Smets R, Brasseur D, Dramaix Wilmet M. Etude d’une cohorte d’enfants admis dans un hopital pediatrique du Sud-Kivu (Zaire). ACCT-AUPELF-KARTHALA, 1991. 298–303. Collins S, Sadler K, Dent N, Khara T, Guerrero S, Myatt M, Saboya M, Walsh A. Key issues in the success of community-based management of severe malnutrition. Food Nutr Bull 2006;27:S49–82. Doocy S, Tappis H, Haskew C, Wilkinson C, Spiegel P. Performance of UNHCR nutrition programs in
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post-emergency refugee camps. Confl Health 2011;5:23. 26. Tappis H, Doocy S, Haskew C, Wilkinson C, Oman A, Spiegel P. United Nations High Commissioner for Refugees feeding program performance in Kenya and Tanzania: A retrospective analysis of routine Health Information System data. Food Nutr Bull 2012;33:150–60. 27. UNICEF Global reporting update: SAM treatment in UNICEF supported countries. 2012. Available at: http:// www.cmamforum.org/Pool/Resources/UNICEF-global -reporting-update-SAM-2011-fex-43-2012.pdf. Accessed 10 April 2014. 28. Dolan C, Khara T, Acosta AM, Shoham J. A synthesis of lessons: Government experiences of scale-up of Community-based Management of Acute Malnutrition (CMAM). Emergency Nutrition Network, 2012. Available at: http://www.ennonline.net/resources/view .aspx?resid=900. Accessed 23 March 2014. 29. Shoham J, Dolan C, Gostelow L. The management of acute malnutrition at scale: A review of donor and
S51 government financing arrangements. Main report. March 2013. Emergency Nutrition Network, 2013. Available at: http://www.ennonline.net/pool/files/ife/enn-cmam -financing-main-report-2013-web.pdf. Accessed 23 March 2014. 30. Collins S, Sadler K. The outpatient treatment of severe malnutrition during humanitarian relief programmes. Lancet 2002;360:1824-30. 31. Grellety E, Shepherd S, Roederer T, Manzo ML, Doyon S, Ategbo EA, Grais RF. Effect of mass supplementation with ready-to-use supplementary food during an anticipated nutritional emergency. PLoS One 2012;7:e44549. 32. Huybregts L, Houngbe F, Salpeteur C, Brown R, Roberfroid D, Ait-Aissa M, Kolsteren P. The effect of adding ready-to-use supplementary food to a general food distribution on child nutritional status and morbidity: A cluster-randomized controlled trial. PLoS Med 2012;9:e1001313.
Paluku Bahwere Abstract
Introduction
Natural and man-made disasters, including floods, droughts, earthquakes, and armed conflicts, create nutrition crises. Unfortunately, the frequency and severity of such disasters have been increasing since the beginning of the 20th century, and their contribution to the burden of acute malnutrition is increasing every year. However, their contribution to the burden of acute malnutrition is underrecognized due to the ways in which global statistics are built and causes of death are reported. Fortunately, the success of the current protocol for treatment of severe acute malnutrition (SAM) and the integrated approach to treatment has created a momentum allowing expanded coverage of treatment of SAM, especially in humanitarian emergency contexts. For this progress to be maintained and accelerated, changes in nutrition information systems at the national and global levels are needed, and the persisting barriers to the expansion and integration of treatment of SAM into routine health systems need to be removed. Emergency funding approaches and objectives have to include sustaining and amplifying the achievements of the short-term palliative interventions. Nutrition programs implemented in emergency contexts have the capacity to contribute to answering priority research questions, and this capacity should be more optimally utilized.
Natural and man-made disasters, including floods, droughts, earthquakes, and armed conflicts, share common characteristics regarding the nutrition situation of affected communities and individuals [1, 2]. In all of these situations, food production and the harvesting of farm produce are disrupted, while access to food from the market is limited by security threats, reduced household income, and the collapse of food distribution and marketing networks. At the same time, food preparation practices and food safety are compromised in a context in which healthcare and sanitation services have collapsed [3]. Such disruption to normal life results in an increased vulnerability to food insecurity and to malnutrition, with the ability to cope depending on the type and severity of the disaster and the gender and age of those affected. Thus, nutritionrelated interventions, including food aid and treatment of severe acute malnutrition (SAM), have rightly been historically part of the first-line emergency response, in addition to the provision of shelter, sanitary facilities, and clean drinking water [2]. Several publications have reported the nutritional impact of emergencies on the prevalence of acute malnutrition and the contribution of acute malnutrition to morbidity and mortality among emergency-affected communities [4–10]. A number of organizations and activists, however, are strongly lobbying against investment of resources in the treatment of SAM and are advocating for a concentration of resources solely for preventive interventions aiming at addressing the determinants of malnutrition by improving habitual diets and child-feeding practices, and reducing exposures to illnesses and food insecurity [11, 12]. This campaign is going on despite the continuous increase in the number of emergencies and the steady increase in the number of displaced people and refugees since the 1970s [13]. The first purpose of this paper is to demonstrate that SAM remains an important public health concern and will remain so for many decades to come if the current trend of increasing frequency
Key words: Burden of severe acute malnutrition, disasters, humanitarian emergencies, nutrition information systems
The author is affiliated with Valid International, Oxford, UK. Please direct queries to the author: Paluku Bahwere, Fond Tasnier, 6, 1332 Genval, Belgium; e-mail: [email protected].
Food and Nutrition Bulletin, vol. 35, no. 2 © 2014 (supplement), The Nevin Scrimshaw International Nutrition Foundation.
S47
S48
of disasters persists. A second purpose is to highlight some issues that distort the reality regarding the burden of SAM. A third purpose is to emphasize the need to use emergency programs of community-based management of acute malnutrition (CMAM) to answer pending research questions.
The increasing frequency and intensity of natural and man-made disasters Regardless of the definition of disasters used, all available statistics from the Centre for Research on the Epidemiology of Disasters and the Centre for Systemic Peace have consistently observed an increase in the frequency and intensity of disasters, especially of natural and man-made disasters. The number of natural disaster events recorded rose from about 100 per decade up to 1940, to nearly 2,800 per decade during the 1990s. After a period of steady decline in the number of armed conflicts in the world, the downward trend has ended and the number of ongoing armed conflicts has been around 32 from 2010 to 2012 [13]. This increase in the number and scale of crises and emergencies over the past decade, as well as the long-lasting nature of most armed conflicts, has resulted in huge population displacement. Since the end of the Cold War in 1991, 30 to 50 million refugees or internally displaced people (IDP) have been recorded annually [13].
Contribution of emergencies to the burden of SAM It is well recognized that the increasing frequency and intensity of natural and man-made disasters is fueling the global prevalence rates of SAM. A review of surveys of acute malnutrition established that between 1988 and 1995, the prevalence of acute malnutrition among children under 5 years of age in internally displaced and conflict-affected populations ranged from 11.7% to 81%, with a median prevalence of 31% [8]. A study of Kurdish refugees from Iraq demonstrated that the increase in prevalence of acute malnutrition occurs very fast during the first weeks of an emergency [4]. The study showed that within 1 month of the onset of the crisis, children under 2 years of age sustained significant weight loss, and the prevalence of acute malnutrition was threefold the normal range in children aged 12 to 24 months [4]. Also, during the first 2 months of the crisis, 12% of infants died, including the great majority of those who developed acute malnutrition, and this situation distorted the picture of acute malnutrition, giving a false impression of no impact of the crisis on infant nutrition status [4]. Statistics currently used to inform policy are obtained mainly by compiling the national data from
P. Bahwere
the UNICEF-supported Multiple Cluster Indicator Surveys and the USAID-supported Demographic and Health Surveys. Caseloads from emergencies, especially from new and acute emergencies, are not included [14]. There is no regular compilation of statistics on SAM among IDP and refugees, and thus it is currently difficult to provide an exact figure for the yearly contribution of emergencies to the SAM burden. A rough calculation using the United Nations High Commissioner for Refugees (UNHCR) figure of 6.5 million new IDP or refugees in 2012, of which 17% were children under 5 years of age, and assuming a prevalence of SAM of 31%, leads to an estimation of 1.1 million cases of SAM from new emergencies not included in the 2012 global estimates of SAM burden. UNICEF figures, which indicate that its humanitarian programs provided treatment of SAM to 2.11 million children in 2012, confirm the high caseload from emergencies [15]. This huge contribution of emergencies to the global SAM burden means that SAM will remain a public health concern, even if preventive interventions are successful in eradicating SAM in stable conditions. To have a good representation of this contribution, systems such as the refugee nutrition information system have to be improved and reorganized to allow good estimation and forecast of the contribution of emergencies to the SAM burden. Review of mortality data during recent humanitarian crises in Africa (table 1) reported under-five mortality 3.6- to 60-fold the baseline rates [9, 16]. Abundant literature has demonstrated that SAM is a major contributor to this mortality [4, 9, 10, 17–19]. As in nonemergency contexts, the contribution of SAM to mortality occurring during emergencies is not sufficiently highlighted in global statistics because of the way the international system for collection of data on cause of death is organized [20]. Although it is already possible to code malnutrition as cause of death using codes E40 to E46 of the ICD-10 (International Statistical Classification of Diseases and Related Health Problems 10th Revision), as did Sacarlal and colleagues for their review of mortality in Mozambique [21, 22], this is not yet common practice, and the ICD-10 system and guidelines still favor the selection of infections complicating SAM as the primary cause of death. However, despite the limitation when attention is paid to these codes, SAM ranks high among the leading causes of death in children. In the Mozambique review, SAM, with 2.1 deaths per 1,000 child-years, was the third leading cause of death among children aged 1 to 4 years after malaria (6.1 deaths per 1,000 child-years) and diarrheal diseases (2.3 deaths per 1,000 child-years) [21]. Some authors have avoided the underestimation of malnutrition as a cause of death by systematically attributing an infectious and a nutritional cause to each death [23]. This approach, which is in line with the philosophy of the Integrated Management of Neonatal and Childhood Illness, has the advantage of reflecting
S49
Severe acute malnutrition during emergencies
TABLE 1. Relative mortality in African famines or recent complex emergencies
Country Somalia Sudan Malawi Ethiopia Ethiopia Kenya Somalia DR Congo Southern Sudan Ethiopia
Survey year
Baseline mortality (deaths/10,000 days)
1980 1986 1986 1989 1991 1992 1992 1994 1998 2000
0.6 0.6 0.5 0.6 0.6 0.6 0.6 0.5 0.6 0.6
Observed mortality Ratio of observed (deaths/10,000 to baseline days) mortality 11.3 10.1 1.8 2.4 5.0 7.4 17.0 30.0 20.0 3.2
18.6 16.8 3.6 4.0 8.3 12.3 28.3 60.0 33.3 5.3
Source: adapted from Toole and Waldman [9], Salama et al. [16].
more accurately the burden of both the infectious diseases and SAM, and should be tested on a larger scale.
Improving coverage of emergency response CMAM has been part of the package in almost all the emergency responses, and this approach is allowing the humanitarian community to cost-effectively cope with the number of cases of SAM during emergencies while meeting the minimum recognized SPHERE quality standards [24–26]. Importantly, the good performances observed during the phase of CMAM field experimentation on 23,511 children with SAM treated between 2001 and 2005 have been maintained, despite rapid geographic scaling up [27]. However, as mentioned above, the unmet need remains huge, and efforts are needed to break the persisting barriers, such as ideological resistance to investment in treatment of SAM by some nutritionists and organizations, the unproductive debate about the type of food to be used, insufficient understanding of the principles and benefits of treatment of SAM among many policy makers, and the scarcity of health personnel skilled in the management of SAM. Also, every single enabling factor and opportunity should be used to ensure that SAM receives due attention. For example, efforts should be made to ensure that the current emphasis on and prioritization of tackling stunting does not reduce resources dedicated to the tackling of acute malnutrition. Usually it is emergency events that create the momentum for getting acute malnutrition onto governments’ agenda and on the list of top priorities for ministries of health [28]. Indeed, in many countries the integration of the management of SAM into routine services and its countrywide scaling up occurred as a result of the momentum created by an emergency, and benefited from emergency funding [29]. Unfortunately, too often the funding for the management of SAM
vanishes after the emergency has ended, as many key decision makers, including government officials, academics, and donors, are still looking at acute malnutrition as a short-term emergency concern. This limits the capacity of many emergency-prone countries to sustain the capacity for management of SAM and for a timely response to subsequent emergencies. This leads to many lost lives at the beginning of an emergency. This situation can be avoided if attention is given during an emergency to ensure integration of management of SAM into routine services and inclusion of SAM in all national nutrition strategy and policy documents. For this to happen, donors should not restrict the use of emergency funding to short-term palliative interventions.
Emergencies as an opportunity for research All of the early research on the effectiveness of CMAM was carried out in emergency contexts [24, 30]. Recently, studies testing the efficacy or effectiveness of specialized food products or different approaches for preventing or treating moderate acute malnutrition (MAM) have also been successfully conducted in emergency contexts [31, 32]. Emergency programs, however, and especially those addressing the needs of IDP or refugees residing in camps, are not yet sufficiently used for addressing research questions, despite the potential they offer. Protracted crises offer the possibility for research related to CMAM with minimal confounding factors, and can offer an environment allowing efficacy trials that are difficult to achieve in other communitybased studies. Confounding factors can be minimized, for example, in studies examining such questions as the most appropriate and cost-effective food for treatment of MAM or SAM, the long-term impact of treatment of SAM, the role of antibiotics in children with uncomplicated SAM, and the appropriate timing of starting
S50
antiretroviral therapy in children with SAM and HIV infection.
Conclusions The current trend of increased frequency and severity of natural and man-made disasters suggests that special efforts are needed to capture accurately the contribution of emergencies and development contexts to the
P. Bahwere
burden of acute malnutrition in global statistics in order to accurately estimate the resources and efforts needed in the fight against malnutrition and to ensure that due attention is given to SAM now and in the future. Because there is still some uncertainty regarding some aspects of the current protocols for management of SAM, it is paramount for the humanitarian community to support research within their emergency programs, given the opportunity that some of these offer for research.
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