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Veronique Priem, Niger, 2002DakoroStabilisationCentreScaling up the treatment of acute childhoodmalnutrition in NigerBy Isabelle Defourny,Emmanuel Drouhin,Mego Terzian,Mercedes Tatay,Johanne Sekkenes andMilton TectonidisMilton TectonidisEmmanuel Drouhin is the Niger Desk Officer, Isabelle Defourney thedeputy Desk Officer for Niger and Mego Terzian is the Emergency DeskOfficer, all based in Paris with MSF France. Johanne Sekkenes is theHead of Mission of MSF Niger and Milton Tectonidis the NutritionConsultant in the Medical Department of MSF France.Field ArticleThis article presents a strong case from Niger thatmanaging severe malnutrition on a large scalethrough outpatient treatment is a real possibility.For a short period during the summerof 2005, Niger – a country whose peopleare amongst the poorest in theworld - had the dubious privilege ofhitting prime time on international television,as officials and advisors attempted to explainwhy so many children were starving and whynothing had been done to help them. Despitea prevalence of wasting constantly hoveringaround or above 15% and the third highestunder-5 mortality rate in the world (259 per1000 live births 1 ), health authorities and theirbilateral, multilateral and international partnerspresent in the country were almostexclusively focused on development programmesaddressing ‘underlying causes’.Food security early warning systems in Nigerwere essentially limited to rainfall data andagricultural production estimates. Theabsence of any sustained attempt to monitor,let alone treat, acute malnutrition, combinedwith a fatalistic complacency towards high‘structural’ rates of wasting, led to unacceptabledelays and errors in the response to theepidemic of malnutrition that affected Nigerin 2005.The development of solid equivalents oftherapeutic milks in the last five years isinspiring a major change in the treatment ofacute malnutrition 2,3,4 . These nutrient-denseReady to Use Therapeutic Foods (RUTF) haveled to the development of an outpatientapproach to treatment based on simplifiedmedical and nutritional protocols for all butthe most complicated cases. In rural settings,multiplication and decentralisation of programmeentry points leads to rapid and thoroughdiagnosis of wasted cases in the community.Effects on programme capacity andcoverage are dramatic and costs per patienttreated reduced. Programme indicators suchas cure, mortality and default rates have, tothe surprise of many, consistently outperformedthose obtained with the classicapproach advocating predominant or exclusiveinpatient management 5,6 .Applying this new strategy to the crisis inNiger in 2005, Médecins Sans Frontières(MSF) expanded operations well beyond theprogramme established in Maradi region in2001, going on to admit over 63,000 severelymalnourished children in therapeutic feedingprogrammes during the year, by far thelargest nutritional intervention in the organisation’shistory. Even outside periods of acutecrisis, home consumption of RUTF has the, asyet, unexploited potential of making theeffective management of acute malnutritionfar more accessible in resource poor countriescharacterised by high malnutrition rates andnumbers of wasted.MSF in Niger and the response to the2005 crisisThe outpatient treatment programme forsevere malnutrition in Maradi was opened inJuly 2001 after a measles epidemic sweptthrough the region. The continuing largenumbers admitted (4,443 in five months)exceeded expectations and led MSF to maintainthe project. The number of admissionsrose every year reaching 9,524 in 2004, bywhich time direct admissions into outpatientcare had increased to over 50% of all admissions.Reluctance amongst clinicians to dischargestabilised patients quickly from theinpatient centre had been overcome, curerates had reached 83.5% and overall mortalityrates had fallen to 6%.In the first few weeks of 2005, the MSFteam in Maradi noticed a distinct change inthe pattern of admissions compared to previousyears. By early February 2005, weeklyadmission rates were triple what they hadbeen in 2004, without any additional deploymenton the part of the existing programme.By mid March 2005, MSF launched evaluationsin Maradi and Tahoua that confirmedhigh rates of acute malnutrition - months earlierthan the usual hunger gap - and began toexpand and extend activities in both regions.Weekly family food rations and a large dischargeration were added to the therapeuticpackage of RUTF and medical care offered toall admitted children. By early July 2005, 45international staff and 660 national staff wererunning 27 outpatient centres (OC) and fivestabilisation centres (SC) for severely wastedchildren. From August 2005 onwards, activitiesin Tahoua and the northern parts ofMaradi were handed over to other internationalagencies, and subsequent MSF effortswere concentrated on the most affected areasof Maradi and Zinder, where the majority ofadmissions for severe malnutrition werebeing recorded. In late September 2005, thefeeding programme in Maradi admitted 2,043new patients and was monitoring 8,727 malnourishedpatients a week, 934 of them in the1Unicef. State of the world’s children 2006: Excluded andinvisible. NY: Unicef 2005.2Briend A, Lacsala R, Prudhon C, Mounier B, Grellety Y,Golden MH. Ready-to-use therapeutic food for treatment ofmarasmus. Lancet 1999; 353: 1767-1768.3Collins S. Changing the way we address severe malnutritionduring famine. Lancet 2001; 358: 498-501.4Community Based Therapeutic Care (Khara T. Collins, S.ed). ENN Special Supplement Series, No. 2, EmergencyNutrition Network, November 2004.5Collins S, Sadler K. Outpatient care for severely malnourishedchildren in emergency relief programmes: a retrospectivecohort study. Lancet 2002; 360: 1824–1830.6Ciliberto MA, Sandige H, Ndekha MJ, Ashorn P, Briend A,Ciliberto HM, and Manary, MJ. Comparison of home-basedtherapy with ready-to-use therapeutic food with standardtherapy in the treatment of malnourished Malawian children:a controlled, clinical effectiveness trial. Am J ClinNutr 2005; 81: 864 –870.2