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Childhood Malnutrition: What happens now?
October 13, 2011
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In 2010, Doctors Without Borders/Médecins Sans Frontières (MSF) launched a campaign to call on donor governments to stop providing sub-standard foods with insufficient nutritional quality to malnourished children living in developing countries.
Most of the damage caused by malnutrition occurs in children before they reach their second birthday. This is the critical window of opportunity, a time when the quality of a child’s diet has a profound and sustained impact on their health and physical and mental development. For young children, the principles of good nutrition are well established. They center on good maternal nutrition and breastfeeding for the first six months followed by the introduction of a nutritious and diverse complementary diet containing some animal source foods, such as milk, meat, and eggs.
Diets that do not provide the right blend of high-quality protein, essential fats, carbohydrates, vitamins and minerals can impair growth and development, increase the risk of death from common childhood illness, or result in life-long health consequences. Yet the cereal-based fortified flours donated as food aid do not meet these basic nutritional standards.
The international standards on how to meet a child’s nutritional needs are being changed, but far too slowly
The Starved for Attention campaign hopes to rewrite the story of malnutrition, by convincing governments to ensure food aid also targets the specific needs of young children with adequate nutritional products. More than 123,000 people from over 180 countries joined MSF in the campaign against childhood malnutrition.
The war and drought-fuelled humanitarian crisis in Somalia and neighboring countries serves as a poignant reminder of the need to act. In this report, we take stock of the progress achieved since the campaign began and assess what still needs to happen to ensure vulnerable children can access the nutrient-rich, energy-dense foods they need to escape the burden of malnutrition.
From Policy to Practice: Improved policies and guidelines, but considerable challenges remain
The policies of the United Nations agencies that distribute food aid have evolved. Together, three UN organizations—the World Food Program (WFP), UNICEF, and the UNHCR, which works with refugees—are responsible for a significant proportion of the food aid that is distributed internationally to the most vulnerable children. Until recently, there were no formalized guidelines to ensure children’s needs were addressed. Today, all three UN agencies now firmly acknowledge the need to ensure the nutritional quality of the products they distribute. Ready-to-use formulations are now included in the range of products these agencies use, along with cereal-based fortified flours that have been improved through the addition of milk. The policies of all three agencies now clearly establish that flours that have not been augmented with milk are not sufficient to tackle childhood malnutrition and should only be distributed as a last resort to children under the age of two.
The international standards on how to meet a child’s nutritional needs are being changed, but far too slowly: In late 2008, an expert meeting convened by the World Health Organization (WHO), the world’s leading agency on health, considered the growing body of scientific evidence and concluded that nutritional standards of food aid needed to move away from cereal-based fortified flours. This position from nutritional experts is widely shared and was even formalized in a letter written by the heads of UNICEF, WFP and WHO in March 2010. But, unfortunately, the guidance the WHO gives countries on how to meet a child’s nutritional needs has still not been published as of yet, and it’s unclear when it will be released. The latest draft is a mixed bag: while it recognizes that protein sources should preferably come from animal foods like milk, eggs or meat, it regrettably does not give precise guidance on how much of this kind of protein should be included in nutritional products provided to young children. Without guidance from the WHO, it will be hard to convince countries of the need to change the nutritional quality of the foods they distribute, or for other regional bodies such as the African Union to encourage countries to tackle malnutrition as an essential health intervention.
Some of the biggest food aid donors are looking to upgrade their policies: Every year the United States sends more than 130,000 metric tons of fortified corn-soy blend flour (CSB) to nutrition programs, primarily in sub-Saharan Africa. These flours, grown on American farms and processed in American factories, are used as porridge to feed malnourished children or those under the age of two. Tragically, they do not meet the nutritional requirements of these children. In 2009, USAID asked Tufts University to conduct a Food Aid Quality Review and to recommend changes. The Tufts’ report adds to existing scientific evidence that current food aid does not meet the needs of young children.
The report cited a need to improve the nutritional composition of CSB currently distributed by USAID and to add foods specifically designed to address childhood malnutrition, such as ready-to-use supplemental foods (RUSF), to the list of products that can be distributed as a part of food aid. This positive trend is a further clear signal of the need for change, but it does not go far enough. The proportion of animal-source foods that the Tufts report recommends is less than that of the improved corn-soy blend (known as CSB++) pioneered by WFP and UNICEF and nutritionally enhanced to meet a young child’s dietary needs. This therefore means that children receiving food products supplied by USAID risk receiving products that are inferior to the ones used by the UN.
In addition, the US will still continue to distribute its own variety of CSB. It is, admittedly, an improved version of CSB, but far better products exist. Unlike the WFP, which developed adapted products for children on the one hand and adapted products for adults on the other, the US will continue to rely on a one-size-fits-all CSB, which will not contain the optimal amount of dairy to meet the nutritional needs of children. Such a move also complicates distribution, because those distributing the food aid have an additional product to contend with; it would be simpler for the US to apply, as other food aid donors do, the standards that the WFP has published.
Another food aid giant, the European Commission (EC), is also falling short. Despite repeated pledges about the need to ensure that the nutritional needs of children under two are met, the EC has yet to publish clear guidelines about how to make this happen. Some European countries are already providing quality products as a central part of food aid – but the money that comes from the Commission level is not necessarily spent on such products. Planned policy announcements have also been delayed even as the distribution of substandard products continues to receive EC financing. This is particularly regrettable given that a strong, unambiguous guideline from the EC would have a ripple effect and would help European countries ensure that their own food aid policies address the needs of children.
The lack of a precisely targeted policy response to nutrition by the EC has an immediate impact on their practical interventions, which are equally incoherent. The EC finances the use of some products that meet a child’s nutritional needs, including milk-based pastes fortified with vitamins and minerals and other essential nutrients that MSF uses in its own programs. But such financing has strings attached that significantly restrict their use: programs that will use improved nutritional supplements (CSB++, RUSF) have to commit to providing evidence on the benefits such products have on the children who receive them even though no such demands are made of EC-financed programs distributing products that are known to be far less effective, like CSB.