Following an outbreak of measles in Borno state, northern Nigeria, in March 2005, Doctors Without Borders/Médecins Sans Frontières (MSF) conducted an emergency intervention. While the number of measles cases decreased, the nutritional status in the area was found to be of great concern, notably among small children. Meanwhile, MSF's feeding center filled up with malnourished children, many of them fighting for their survival. MSF emergency coordinator Ton Koene talks about the situation and MSF's reaction.

What is the situation like in Borno state?

Our teams screened more than 2,500 children in different villages of southern Borno state and found that between one and two percent of them were suffering from severe acute malnutrition (SAM).

MSF therapeutic feeding center in Biu hospital, Borno state, Northern Nigeria: The nutritional status of a child is checked by using the MUAC (Middle-Upper-Arm Circumference) bracelet. Photo © Ton Koene

This means that the child's weight falls below 70 percent of what is normal. This is quite alarming and particularly unacceptable in conflict-free Borno state. In the area where we work right now we expect up to 900 severely malnourished children who might die if they don't get medical care and nutritional support. And this number only represents a small part of Borno state.

Why are so many children undernourished?

The reasons are multifaceted. There are several chronic factors such as mainly young mothers who stop breastfeeding too early and are unable to give their babies a healthy, varied diet. Chronic food insecurity is another problem that not only affects northern Nigeria but a sub-Saharan zone spanning from Mauritania to Niger and Sudan to Ethiopia. Food stocks are depleted because rains have been patchy for years and last year locust swarms devastated many crops. And the next harvest is only due to start in November. While children were already weak due to the food gap, bad diet, and poverty, a measles epidemic aggravated the situation at the beginning of this year. Already vulnerable children were hit extra hard. As a consequence, we can see a relatively high level of severe acute malnutrition among children under five years of age.

What is MSF doing to address the problem?

MSF therapeutic feeding center in Biu hospital, Borno state, Northern Nigeria: Children receive up to eight meals of special high-protein milk around the clock until they have gained enough weight. Photo © Ton Koene

MSF has set up a therapeutic, or intensive care, feeding center, in Biu hospital, the main referral hospital for the region. The building can accommodate 50 to 60 children. Additional tents have been put up in the hospital compound to eventually increase the feeding center capacity to up to 100 children. At first, staff members weigh and measure children to get a more accurate idea of their condition. Then they receive up to eight meals of special high-protein milk around the clock until they have gained enough weight to be released. At times, the little ones are so weak that they no longer even have the strength to swallow. In such cases, they have to be fed through a tube to their stomach or put on a drip. The problem is that people are very dispersed in the district and do not necessarily know about our services. That is why we send a mobile outreach team to the main villages. Together with local authorities, MSF staff invites all children under five years old to gather on the village square or under a big tree. MSF aid workers identify the most severely malnourished by measuring height-to-weight ratio, and take the severely malnourished children with their mothers to the feeding center in Biu.

What is the atmosphere like in a feeding center?

The building and the additional tents are quite crowded. Somewhere there are always some babies crying, mothers are busy feeding them, the feeding center team is running around doing check-ups or handing out the special milk formula. It is hard to see a child dying, even for the experienced medical personnel. In the beginning it happened almost every day because we were receiving many children who would have needed treatment much earlier. Through widespread nutritional screening by our mobile teams we are able to identify and treat the most serious cases at a much earlier stage. But still, some two-year-old kids weigh just under three kilos (7 pounds), which is less than a child should weigh at birth. They are lethargic, have wrinkled faces, and their skin resembles parchment paper. There's a lot of sadness in a feeding center. You see women who have to go back home with the body of their dead child. But there is also a lot of relief and happiness when you see that children are improving, that they are recuperating and gaining weight

How long do the children have to stay in the therapeutic feeding center?

Normally, the mother and her child should stay up to six weeks in order to complete the treatment. However, a lot of mothers and children leave after one or two weeks. The women feel pressured to go back home for many reasons. At the moment it is planting season, so they are needed in the fields. Back home they have other children who need care. Finally, in predominantly Muslim northern Nigeria, where men usually have several wives, a woman who is leaving home for several weeks will lose social status within her family. The only thing we can do is to explain to the women and their husbands how important it is to finish the treatment. We have also adapted our services to the women's constraints: As soon as the children have passed through the most critical period in the feeding center, mothers can take them home. They will then come back on a weekly basis to certain main villages, where our teams provide ambulatory medical follow-up and therapeutic food rations.

The project is intended to run until the end of this year. Why is the intervention limited in time?

MSF therapeutic feeding center in Biu hospital, Borno state, Northern Nigeria: An MSF physician examines a severely malnourished boy who needs to be fed through a tube to his stomach. Photo © Ton Koene

MSF neither can nor intends to address the chronic aspects of malnutrition. To solve those problems, MSF would have to deal with deeply rooted social and cultural aspects and would have to get involved into developmental issues such as agricultural schemes and long-term education. This is not our role as an emergency medical humanitarian aid organization. MSF focuses on lifesaving medical activities during periods when people are affected by an acute crisis like conflict, epidemic, nutritional crisis, or natural disaster. We hope that with measles complications fading away and the new crop being harvested, mortality among children will be back to normal levels by the end of this year. We can then hand our services over to the local hospital and support it with medical and nutritional supplies for a certain time. In this way, our team can move on to other emergency situations where people are in even more dire need of support.

What is going on in Katsina state?

MSF medical teams conducted a nutritional survey in the northern state of Katsina, which borders Niger, and found a severe acute malnutrition rate of three percent. Based on population figures available, the teams are expecting to treat as many as 6,000 severely malnourished children under the age of 5. MSF is working to understand the factors that may have contributed to the sharp increase in malnutrition in Katsina. We are conducting a food security survey, and believe that, as in Borno State, many of children were also affected by a measles outbreak this spring. MSF has already established a therapeutic feeding center in the General Hospital of Katsina to provide around the clock care for severely malnourished children with additional medical complications. In addition, six ambulatory feeding centers have been established in the northern part of the state to provide weekly checkups and food rations to the severely malnourished children who are strong enough to remain at home during their treatment.