September 30, 2010

Inside an MSF outpatient clinic for malnourished children in northeast India, Dr. Krishna Ashvalayan is trying fervently to convince a mother to keep her severely malnourished 12-month-old girl in MSF’s nutrition program. The girl’s mother, Sela, however, is adamant; she wants her daughter’s name taken off the clinic’s list of patients.

India 2010 © Stephanie Sinclair/VII

Dr. Krishna examines a child in the ambulatory therapeutic feeding center(ATFC) in Biraul town.

Inside a Doctors Without Borders/Médecins Sans Frontières (MSF) outpatient clinic for malnourished children in northeast India, Dr. Krishna Ashvalayan is trying fervently to convince a mother to keep her severely malnourished 12-month-old girl in MSF’s nutrition program.

The girl’s mother, Sela, however, is adamant; she wants her daughter’s name taken off the clinic’s list of patients. She insists that she simply cannot make weekly trips from her home village to the clinic for check-ups and supplies of nutrient-rich ready-to-use therapeutic food (RUTF).

India 2010 © Stephanie Sinclair/VII

Mothers Laila, left, and Sela, right, laugh inside MSF's ATFC in Biraul town.

Days she comes to this clinic in the town of Biraul, she explains, are days she cannot earn money harvesting wheat in someone’s field. And to get here, she has to leave her home early in the morning to catch the train that takes her into Biraul. If treatment takes too long, she risks missing the last train back, meaning she has to pay for a ride home on either a motorized rickshaw or a makeshift bus that costs far more than the two-rupee train ticket. What’s more, this daughter is not her only child. “I have six other children at home,” she says. “Who is going to feed them?” Underlying her skepticism is a sense that her child, who looks like most of the other children in her village, is not really sick.

A Different Kind of Emergency

India is a complex country in which to launch a program that targets a condition that can be invisible, or at the very least, hard to detect. A year and a half after MSF, in cooperation with the local health authority, opened its program for children with severe acute malnutrition (SAM), 3,000 patients have completed treatment. These children are now more likely to develop physically and mentally at a normal rate, more likely to have healthy immune systems, and less likely to get sick and die due to diarrhea or influenza. But 3,000 is a tiny number in Bihar, a state with a population of 100 million—let alone India, which is, according to UN figures, home to one in every three malnourished children in the world.

“This is a very strategic project where we can’t hope to meet the needs of all of the people,” says Dr. Gareth Barrett, medical coordinator for MSF in India. “But we do hope to demonstrate that there is a way to treat severe acute malnutrition.”

India 2010 © Stephanie Sinclair/VII

A child's middle-upper arm circumference is measured by an MSF health worker at a mobile ATFC.

MSF is working in Darbhanga District, an area of Bihar that is flooded every year by monsoon rains and where an estimated five percent of children under five years old suffer from SAM. This is one of the poorest areas of India, a region that boasts few signs of the development found in a place like Mumbai. Much of Bihar’s population lives season to season, dependent on rainfall and good harvests. Schools and hospitals are few in number, and health care is limited. Nutritious foods are available, but they are expensive. People who cultivate fruits or vegetables, or get milk from their buffalos or goats, are more likely to sell these nutritious foods for income than to keep them for their family.

This has led to a pattern of nutritional insecurity—or a lack of consistent access to nutritious foods—that has become a fact of life for generations of Biharis. Dr. Barrett estimates that half the state’s population has had their growth stunted. It is so common now that it has ceased to look unusual. And the phenomenon has become almost self-perpetuating.

India 2010 © Stephanie Sinclair/VII

Severely malnourished children who have life-threatening complications are admitted to MSF's stabilization center.

“The child grows up to be stunted, gets married to another stunted child, the child born to them will be stunted,” says Dr. Krishna. “So this is a chronic process that has been happening since time immemorial.” And as Dr. Krishna learned when he was trying to convince Sela to keep her daughter in the program, it can be difficult to convince a parent that they need to bring their child to a clinic every week for care.

The impact goes far beyond physical stunting. Malnourishment can also delay a child’s mental development. Like    physical growth, brain development also relies on the right balance of micronutrients. “We have a lot of mothers coming with a complaint of, ‘my child is two-and-a-half or three years old and is not walking. My child is three years old and is not speaking yet,’” says Dr. Krishna. “The reason being the child has not been getting the proper nutrients for its development.” For these kinds of cases, RUTF can play a vital role in rehabilitating the child. But it is critical for children to get the right foods within the first two years of life, and it is critical that mothers understand that in such circumstances, once their child is six months old, breastfeeding alone is not enough.

Building a Medical Model

MSF’s nutrition program in India stands in contrast to its emergency treatment of SAM in other places. This is not Ethiopia in 2008, when children were in immediate danger of dying and desperately needed emergency treatment. And this is not like one of MSF’s current projects in Niger or Chad, countries where children are caught in a potentially fatal cycle of seasonal hunger gaps. But the fact is that SAM among children five and under continues to be an ongoing problem with far-reaching consequences in India, and thus far it has not been effectively addressed.

India 2010 © Stephanie Sinclair/VII

A mother feeds her child in front of the MSF stabilization center.

“The population today is undernourished,” says Dr. Barrett. “There is no other way of saying that people don’t have access to a well-balanced diet. But until things do improve, there is a need to treat people. With severe acute malnutrition, people today are vulnerable to premature death and long-term damage.”

MSF runs one inpatient stabilization center for children who are severely malnourished and in danger of dying. Children are fed gentle therapeutic milk packed with micronutrients that their bodies can absorb until they are stable enough to receive RUTF and regular food. But 8 out of every 10 children in the program are treated as outpatients, receiving weekly consultations with a doctor and rations of RUTF. Mothers like Sela bring their children to one of three ambulatory therapeutic feeding centers on appointed days. If they miss a week or two, health educators are sent out to their homes to find out why and to convince them to come back.

India 2010 © Stephanie Sinclair/VII

An MSF doctor examines a child at one of the mobile ATFCs in Biraul.

While patients are being treated, health workers collect data. The idea is to refine this small pilot program so that it can soon serve as a highly effective and cost-efficient model that can be replicated by other organizations or health authorities throughout the country. “What we’re trying to do in India is treat children, but then take the results from that and share that with the Indian government, share that with other organizations,” says MSF nutritionist Jeanette Bailey. “And we’re trying to show that it’s very simple, that it’s absolutely possible, and that there’s no reason we can’t do this on a large scale.”

Success Through Word of Mouth

Health education at the clinics is designed to sensitize mothers to the nutritional needs of their children, along with other health and hygiene practices, and the necessity of continuing the treatment until their children are fully recovered. The team’s communications efforts only go so far, however. The best ambassadors for the program, as it turns out, are mothers of children who are in the program and who have completed treatment.

It has been several months since MSF teams finished screening children in the villages of the area it serves and directing the parents of malnourished children to come to the clinics. Yet a stream of new patients continues to show up seeking care. This is due to word of mouth, says Dr. Krishna, mothers talking to mothers and elders talking to young families, spreading the message through community networks.

India 2010 © Stephanie Sinclair/VII

Sela walks to the station to catch the train to Biraul town.

With Sela, Dr. Krishna has tried every argument he could think of in an attempt to keep her in the program. It seems that he was unsuccessful, however, and she appears to be preparing to leave the clinic for the last time. Just then, Laila, another young mother from Sela’s village, whose child is receiving a consultation right behind her, chimes in. “You should stay in the program for the good of your child,” Laila says.

The other mothers in the rooms instantly begin echoing the sentiment, breaking down Sela’s resistance with their own conviction until, finally, Sela relents. “Okay, I will come back,” she tells the relieved doctor, making a seemingly simple decision that may very well have a profound impact on the rest of her child’s life.