Niger: taking political responsibility for malnutrition

No one knows how many people in Niger will suffer from acute malnutrition in 2006. The nutritional crisis may well be less severe this year than last, but equally it may be as bad, or worse. But however many people suffer, it will no longer be possible to refuse to take responsibility, deny that a nutritional emergency exists or pass the buck for and scale of the nutritional crisis.

This crisis has been substantially underestimated; we now think that tens of thousands of children suffered from acute malnutrition in previous years. Retrospective examination of the total number of admissions in MSF programmes in Maradi between 2001 and 2005 shows that the nutritional crisis must have been very serious in 2001. Over the last five years, admission figures in nutritional programmes in Maradi region have risen constantly (5,200 in 2002, 6,700 in 2003, 9,700 in 2004). This leads us to conclude that acute malnutrition is hyperendemic, with ‘epidemic peaks’ in certain years. Acute malnutrition can be described as a chronic emergency.

Faced with this problem, the health authorities, NGOs and UN agencies ran development programmes until the first half of 2005. The response to the emergency was minimal and inappropriate. Until June 2005 the aid system (donor agencies and the UN) supported the government’s decision to make people pay for food aid, on the grounds that free aid unbalances markets, creates welfare dependency and ultimately negates development efforts. There was a political trade-off between preserving human life in an emergency and long-term development imperatives. When they were finally launched, food distributions essentially targeted areas where there had been a shortfall in production, taking no account of malnutrition indicators (admissions to nutrition centres). Rations supplied by the World Food Programme (WFP) did not include specialist foods such as enriched flour suitable for the nutritional needs of young children.

Manufacturing hunger

The nutritional crisis was predominantly put down to natural phenomena (drought and pest infestation). While it is true that there was a shortfall in millet production in 2004, it was still one of the best growing seasons in Niger’s history. Moreover, MSF’s experience shows that malnutrition does not fall following good harvest years (as in 2001 and 2003). The place where acute malnutrition is most prevalent – Maradi – is in the heart of the agricultural production zone, a region known as the granary of Niger. In other words, the problem is less the size of the harvest than access to food in sufficient quantity and quality.

Analysing the crisis from the economic viewpoint means looking at the political choices made. If trade rather than production of millet is considered, a consistent picture of malnutrition begins to emerge. Unlike the agro-pastoral zone, where most production is for self-consumption, in southern areas millet is increasingly a market commodity. Millet is sold by small farmers at harvest time, and bought up by traders at the lowest price. Cash resources remain low, and are inadequate to cope with unexpected expenses or to purchase sufficient quantities of millet during the hungry season, when prices are at their highest. Being more dependent on the market for their food supplies, the poorest households are the first to suffer from rising prices. There is an extremely high and troubling correlation between weekly trends in millet prices and admissions to the MSF programme. Millet price rises are followed by admissions precisely five weeks later.

The impact of pauperisation on the nutritional status of children under five can be seen from admission figures at nutrition centres. Over the last five years, admissions have been extremely seasonal, with a peak in the hungry season when stores run out before the next harvest. This is the period between June and October but, in each of the last three years, we have noticed an increase in admissions five weeks earlier than the previous year, meaning that the critical periods have been getting longer and longer.

MSF’s nutritional strategy

The aim of MSF’s nutritional programmes in Niger is to reduce mortality associated with acute malnutrition by providing nutritional support and free medical care in the areas worst affected by the crisis. Children admitted to the programme receive therapeutic feeding (Plumpy’nut©, F100), specialist foods (enriched flour) and, on discharge, family rations (millet, beans and oil).

The outpatient system lies at the heart of MSF’s operations in Niger. Set up in 2003, the system helps minimise non-essential hospitalisations. Children presenting with complex malnutrition (severe medical complications and/or anorexia) are hospitalised. Others remain with their families to receive treatment, with a weekly medical check-up at a centre close to their homes. The system was made possible by a medical innovation: ready to use therapeutic food, which keeps for several months. The child consumes the food directly in individual rations, with no addition of water and no container required.

This revolution in dealing with malnutrition enabled MSF to care for more than 63,000 children in 2005, by far the largest nutritional operation ever carried out, and with very good results. The rate of cure was above 90% in 2005, the dropout rate was reduced to 5% and the mortality rate was 3.3%. Children’s average stay within the programme as outpatients was 29 days (compared to 37 days in 2002) and average weight gain was 10.4g/kg per day (compared with 8.7g/kg per day in 2002).

When will the response be delivered?

Does the will to tackle this chronic emergency exist? There are more aid providers in the country and strategies are being developed. While MSF can see some movement on the ground at the beginning of 2006, donor support does not seem to be commensurate with needs. Moreover, experience in 2005 has shown that several measures relating to the free provision of food or medical care for malnourished children were implemented very late, or on a small scale. MSF is waiting for commitments to result in concrete action in the field.

Two essential measures still need to be implemented: treating acute malnutrition with effective, ready-to-use therapeutic foods, and making available food that corresponds to the nutritional needs of small children. After 2005, it is no longer possible to deny the nutritional challenge in Niger, or the responsibilities that need to be shouldered.

Emmanuel Drouhin is Programme Officer for Niger for MSF. Dr. Isabelle de Fourny is Assistant Programme Officer. The authors can be reached at office@paris.msf.org.