For the past year I've been running a children's ward in rural Tanzania. Every day I treat severe acute malnutrition (SAM), a condition responsible for over half a million deaths in under-fives each year. These children are either emaciated, weighing less than 70% of what they should, or have oedematous malnutrition, where their legs, and in severe cases, whole bodies, become swollen.
Without calorie-dense micronutrient-enriched therapeutic foods up to two thirds will die. Managed properly, even in a basic setting like ours, we can reduce this by over half. Actually getting hold of the therapeutic baby food is the biggest challenge of my job, and one faced by frontline healthcare providers across Tanzania.
This week I am called to see Faraja, a four-year-old girl with SAM. She is weak from a combination of starvation and infection, and cannot swallow without food going into her lungs. I inject antibiotics and place a tube through her nose to drip milk into her stomach. It is a precarious balance between giving enough to prevent fatally low blood sugar, and avoiding stressing her fragile metabolism and undernourished heart. Two days later, despite regular feeding, the infection is overpowering. I give CPR. It is a formality. Faraja's file joins a pile of three others on my desk, all children lost to malnutrition this month.
Faraja had more chance than most, arriving when therapeutic foods are in stock. The World Health Organisation recommends two pharmaceutically prepared formula milks, F75 and F100. These contain a combination of powdered cow's milk, sugar, fat and micronutrients, specifically proportioned for a starving child's metabolism. By adding clean water you have most of what is needed to treat malnutrition. It is liquid, allowing us to give by tube to semi-conscious children like Faraja. The disadvantages are cost, and reliance on a supply chain. Within Tanzania, it is only available through UN agencies and NGOs.
Our three boxes of formula milk will soon run out, with no guarantee of replacement. We contacted the UN for assistance after seeing numbers of children admitted with SAM double in 2013, and then double again this year after floods destroyed crops and infrastructure.
Unicef runs a programme supporting treatment of SAM in our region, and the NGO prompted our regional hospital to supply us with therapeutic milk. We were told only three boxes could be spared. This is enough to treat two or three children for the six to eight weeks required to recover from SAM. This week alone we admitted two new cases.
Admittedly, the need is huge, and formula milk is not a sustainable solution in a country where nearly 2% of under-fives are severely malnourished. But it can help some, and failures of the government and UN agencies to distribute scarce resources appropriately are frustrating. When I visited the storeroom of the regional hospital to collect our supply, I noticed several unopened boxes which expired last year.
When formula milk is not available we struggle to make our own. The WHO suggests a cheap cereal-based alternative made from locally grown maize and soya. Cereals require cooking to be digestible and, like most hospitals in rural sub-Saharan Africa, we have no kitchen. We quickly realised the impracticality of asking nurses to burn charcoal on the ward to prepare feeds.
Most often, we use a more expensive alternative, mixing powdered milk with sunflower oil, sugar and water to approximate the pharmaceutically prepared formula milks. The ingredients require careful weighing by a nurse caring for a ward full of sick children. Errors are frequently made. Furthermore, we must find micronutrients to enrich the foods. A ready-mixed micronutrient powder is available, but only along the same supply chain as the pharmaceutically prepared milks. We substitute this with vitamin and mineral tablets. Some, like zinc, are easily found due to its widespread use to treat diarrhoea, but we cannot find the more obscure elements, like selenium, copper and magnesium.
The World Food Programme, Reach and Scaling-up Nutrition are working with the Tanzanian government to improve nutrition. There are good evidence-based policies to move treatment of stable children with uncomplicated SAM into the community, and feed with locally available foods. But there is little mention of how we should feed children with complicated SAM, like Faraja. They arrive unconscious, sometimes hours from death. Hospital treatment with easily prepared formula milk offers the best chance of survival. But where will this come from?
Ultimately, prevention is much more effective than cure. Feeding severe cases helps a few, it doesn't untangle the social and economic causes of malnutrition. The government and their partners will help many more by promoting breastfeeding, diversifying crops and fortifying food. But as a doctor the immediate concern is the person in front of you. For now, we will continue to make an imperfect difference trying to save children like Faraja.