15 August 2009

Heartbreaks

Plumpy Nut. I never thought fortified peanut butter could bother me so much.
Last week I wrote about the malnutrition clinic (called CNTA) at Mungele. There are basically two levels of malnutrition care here: inpatient (called CNT for "Centre Nutritionelle Therapeutique") and outpatient (CNTA- the same but with "Ambulatoire" at the end). In order to get cared for as an inpatient (the CNT in the central hospital in Lubutu) a child must have Moderate or Severe malnutrition and have some other symptom or medical complication: anorexia, severe anemia, severe infection, of just look apathetic and exhausted.
The criteria for the CNTA, however, are different. Kids have to be Severely malnourished but free of those other medical issues. They are basically starving to death but not really "sick".
To get some perspective on this, even if a child is only Moderately malnourished, they look very skinny. Their arms are tiny and their ribs are easily visible. They do not look healthy.
Unfortunately, if you are "well" but only Moderately Malnourished, you don't qualify for CNTA. The Consultants and I take your history, examine you, and probably end up giving you some vitamins and some albendazole for intestinal parasites. We sit down with your parent and tell them that they should try to feed you more.
Why aren't we treating everyone with malnutrition (mild, moderate, severe) to the full extent possible? Apparently, for the general population here, obtaining food is not such a big challenge. Things grow easily. The jungle is apparently full of stuff to eat (both animal and vegetable), and there is no drought or war or anything else in the way of people getting food. Studies have been done in this geographical area that demonstrate only one planting/harvesting season per calendar year. This is amazing to me as plants here appear to visibly grow by the minute.
In other MSF projects where people are hindered from finding food by famine or war, access to food is obviously harder. In these other places, even Moderately malnourished "well" children qualify for the CNTA with free food supplements, a mosquito net, and a cocktail of medicines to help them get fatter.
The other confounding factor in the equation is that apparently mortality rates are not much higher for Moderately malnourished children than for normal kids. Since MSF resources are limited and the average person here isn't really prevented from obtaining food, it is harder to get help for your moderately Malnourished kid in Lubutu than it might be elsewhere in Africa, even within MSF. If it is true that Moderately malnourished children are not more likely to die than normally fed children, perhaps resources should be concentrated only on curing Severely Malnourished children (who do have a higher mortality) and encourage programs (non-MSF) that help people find food. Like how about two or three plantings/harvestings per year instead of just one?
Today we saw the CNTA patients back after their first week enrolled in the program. One kid stayed the same, but the rest of them gained weight. A lot of weight. Plumpy Nut is 500 calories per package. Since the children get 2 or 3 packages per day, they quickly pack on the pounds. After only one week they looked chunkier and healthier. But we still have to turn those Moderately malnourished kids away hoping they would gain some weight in the next month. Perhaps some kids will have miraculously improved. But without good education about agricultural practices in place, I worry that we might not be doing the right thing by asking these Moderately malnourished kids to wait.
I was initially outraged that we aren't handing out free food to every child here, no matter what their level or malnutrition. Researching this topic, I learned about limited resources and wellness education for communities. I know I'm being idealistic and unrealistic and simplistic. I understand all of this, but I'm here and it is breaking my heart to not give every malnourished kid a big handful of Plumpy Nut.