For Starving Children, a Bite of Hope

By Tina Rosenberg

Nov. 20, 2018

As Americans gather for our most food-centric holiday, there’s some potentially great news about food — especially for people who have very little to eat. It’s a new strategy that could save the lives of hundreds of thousands of hungry children every year.

Fifty million children under 5 suffer from acute malnutrition. It’s one of the biggest contributors to the nearly one million deaths each year of children under 5. Malnutrition wears down the immune system, so a child can die from a cold. It also can cause permanent physical and cognitive damage to children who survive.

Acute malnutrition is easy to treat with therapeutic food. The best-known of these is Plumpy’Nut, a packet of peanut butter, dried milk, oil and sugar fortified with extra vitamins and calories introduced in 1996. It’s very effective for children who get it; one or two packets a day can restore a child to health in a few months. But most children don’t get it. “At best, we are providing treatment for 20 percent of children with severe malnutrition,” said Victor Aguayo, chief of Unicef’s global nutrition program.

Why do we fail children so badly? One reason is we aren’t willing to spend the money. Voluntary donations from governments finance the United Nations’ food programs. The World Food Program is frequently forced to cut food rations and turn people away. Right now, severe child malnutrition in Africa’s Sahel countries is the highest in a decade, but Unicef has only 35 percent of the funds it needs to treat children.

Hunger is rising again after declining for many years. One major cause is climate variability and extremes. The Sahel crisis is due primarily to drought.

But another factor is war. It’s especially hard to work in those war and chaos zones where malnutrition is common. Today the most severely malnourished places are Yemen and South Sudan — both entirely man-made crises. The disruption of war means families can’t work, can’t reach crops and livestock or bring them to market. Health and sanitation systems shut down and workers flee.

But there’s a third reason so many children don’t get help — really bad design. The World Food Program and Unicef share responsibility for feeding children. “There are two protocols, two institutions, two delivery mechanisms, for one group of children,” said David Miliband, the head of the International Rescue Committee, a New York-based agency commonly known as the I.R.C. that works in humanitarian emergencies. “It doesn’t make any sense at all.” (He lays out the case for change here.)

And the system requires desperate mothers to come to the food every week — which can mean walking for miles through perilous terrain, and then waiting for hours — rather than getting the food to them.

The way we save hungry children needs an efficiency overhaul.

Now it may have one. A group of organizations that feed children, including the I.R.C., Action Against Hunger and the Alliance for International Medical Action, have worked in several countries to test a new system that eliminates the duplication. So far, it works. One reason for success is its simplicity; community health workers can diagnose problems and treat children at home very successfully. Even illiterate health workers can do this, employing materials that use drawings and colors.

O.K., successful pilot experiments happen all the time in the social sector. They almost never lead to widespread change. Even when bureaucracies endorse a new idea, officials often fear change and jealously guard their turf. Many a good idea has been studied to death.

But this time might be different. The World Food Program and Unicef are enthusiastic, to the point of running joint pilot programs to test the idea in West Africa. “We are tremendously supportive,” said Lauren Landis, the director of nutrition of the World Food Program. “We believe it’s time for a revolution in the way we address acute malnutrition.”

Here’s how malnourished children have been treated until now: If the child has a complication, such as pneumonia or fever, he or she goes to the hospital. Uncomplicated cases are separated into two categories, severe or moderate. (The test can be a weight/height ratio, the presence of marked water retention in the feet or the circumference of the mid upper arm.)

Unicef treats severe cases, usually giving children Plumpy’Nut packets to take home. The child must come back every week for a checkup and more packets. Children with moderate malnutrition go to a World Food Program feeding center, where they can get food on site and take-home food, often a corn-soy blend, to supplement the family diet.

What could possibly go wrong? You name it.

A large majority of malnourished children can’t reach either program. “Mothers have to walk for hours, and even if they get there, the service might not be available,” said Mesfin Teklu Tessema, senior director of health for the I.R.C.

When programs do exist, a mother has no idea which one to go to. “The referral between programs doesn’t always work,” Ms. Landis said. And it’s hard to make a weekly trip. “It’s common to relapse if the mother is not able to bring the child every week to get the Plumpy’Nut,” said Grace Funnell, associate director of nutrition and health at Action Against Hunger.

Since money is short, it is focused on treating severe cases. That means many children get no treatment for malnutrition until they deteriorate to the point where it is severe. This endangers children and creates extra costs, because they might need hospitalization. It also leads to a lot of relapses, because children can, in effect, be cut off treatment once they are only moderately malnourished.

Even this flawed system, though, is far better than what came before, when hospitalization was the only treatment for severe malnutrition. In the past decade or so, the number of children treated each year has more than tripled.

Much of the increase can be attributed to Plumpy’Nut. The product was developed by the French company Nutriset 22 years ago but took about 10 years to reach widespread use. (It must get each government’s approval, because technically it’s a medicine.)

With Plumpy’Nut, or other similar high-nutrition blends developed since it emerged, a parent can easily treat a child at home. There’s nothing to measure or prepare, and it doesn’t have to be mixed with water, which is often unsafe to drink.

The other factor is the growing numbers of community health workers, who fight diseases like malaria and tuberculosis effectively and cheaply. But they are still not widespread in every country, and few of them deal with malnutrition — in part because the system is so complex.

The Food Program and Unicef have long been aware of the system’s flaws. In 2011, they signed an agreement laying out a division of their labor. “We thought at that time we were clarifying roles and responsibilities,” Ms. Landis said. “But as we’ve gone on, we felt it wasn’t a problem of clarifying. It was more a need to combine more closely, so children don’t fall through the cracks.”

The dual system arose because the Food Program historically has run feeding centers for people of all ages, and one of Unicef’s missions is to train health care workers. So hospitalized children fell under Unicef’s umbrella.

But severe and moderate acute malnutrition aren’t two different illnesses, like colds and pneumonia. The line between them is arbitrary. So why not treat them the same way?

The I.R.C. and Action Against Hunger are now analyzing the results of a randomized control trial in Kenya and South Sudan that employed a new strategy. It simplifies the diagnosis and treats both degrees of malnutrition with Plumpy’Nut at home. The study also looks at the longer-term effects of the treatment and at cost savings.

Ms. Landis said the cost savings would come largely from switching to a single therapeutic food. “Since that’s the largest component of the cost of treatment, we could really save money,” she said. “If we have one pipeline to buy everything, we can optimize the supply chain. And if there’s one thing we know, it’s a supply chain.”

A single, simplified protocol would enable a child to be treated wherever a mother brought him or her. The program becomes easier to manage and can cover more children. And if it’s simple enough for community health workers to use, they can find many more children, catch malnutrition earlier and reduce missed doses.

Mr. Miliband said that the Food Program, Unicef and the World Health Organization should endorse further pilot programs, support shifting as much nutrition work as possible to community health workers, and then, presuming all goes well, make this the new global system.

“In principle, they are broadly sympathetic,” he said.

Only that?

“That might be typical British understatement,” he said. “Now it’s a matter of turning good will into action.”

“Everything we see is promising,” Unicef’s Dr. Aguayo said. “But we’re trying to go as fast as possible, but not faster, in the greatest interest of children’s rights.”

One reason for further testing, Dr. Aguayo said, was to find out how best to ensure that the most severely ill children get help in a system that treats severe and moderate alike. “We will still have limited resources,” he said. “We need to prioritize the children with the greatest risk. I’m sure that we can.”

Jeanette Bailey, the International Rescue Committee’s senior technical adviser for nutrition and the leader of the just-concluded study, agreed that more pilots can test different ways to solve operational problems. But don’t take too long, she cautioned. “If millions of adults were dying of Ebola, there would be outrage,” she said. “Malnutrition kills the youngest among us in a very slow way. It’s been about a decade that we’re not getting past 20 percent coverage. We can’t keep letting generations of children slip through our fingers.”

Tina Rosenberg won a Pulitzer Prize for her book “The Haunted Land: Facing Europe’s Ghosts After Communism.” She is a former editorial writer for The Times and the author, most recently, of “Join the Club: How Peer Pressure Can Transform the World” and the World War II spy story e-book“D for Deception.”

Jennifer Dyer