Niger: Fighting malnutrition and malaria during the annual “Hunger Gap” - Doctors Without Borders

When three-year-old Mohammed Sani arrived at the Magaria district hospital in Niger’s Zinder region, his face was so swollen he could barely open his eyes. He was suffering from kwashiorkor, a form of severe acute malnutrition characterized by swelling in the face and limbs. Without treatment, complications are frequent and potentially life-threatening, with high mortality rates. Luckily, the boy received treatment from Doctors Without Borders/Médecins Sans Frontières (MSF). By the time he left the hospital he was feeding himself and looking around, his once-swollen eyes wide with curiosity. After his discharge, his treatment continued at home: His mother was provided with sachets of ready-to-use food to give him and instructed to bring him to the closest nutritional center every week for check-ups.

Each year in southern Niger, the combination of the rainy season and the “hunger gap”—the annual period after which stored food from the previous harvest has run out but the next is not ready—trigger a spike in rates of malnutrition and malaria. Though advances in therapeutic foods and better-adapted approaches to care have made childhood diseases like malnutrition easier to treat, hundreds of thousands of children are still affected by this chronic, annual emergency. They need timely, free, high-quality health care—especially from July to October, the peak of the hunger gap.

For the last 15 years, MSF has been working with Niger’s Ministry of Public Health to offer children like Mohammed the best possible treatments. The first historical milestone for this partnership was the introduction of ready-to-use therapeutic food (RUTF) in 2005, which was followed by other successful innovations.

In July 2005, widespread poverty and structural issues, compounded by drought and locusts, resulted in a large-scale food crisis in Niger. The nutritional situation became critical and radical measures had to be taken. A national protocol introducing RUTF was approved, which led to a massive expansion of ambulatory treatment for children with severe acute malnutrition. Nearly 70,000 children were treated across the country in 2005, 60 percent of them with support from MSF teams.

Now, in 2019, hospitals with qualified staff and adequate medicines, equipment, and infrastructure play a key role in the fight against potentially lethal diseases like malnutrition. But for a lot of Nigeriens, these resources remain the option of last resort. Many of the children admitted to hospital emergency rooms are brought there when their conditions have already drastically worsened and they are at risk of lasting negative effects or even death. Long distances between rural communities and hospitals, the cost of transport, and other sociocultural factors such as seeking traditional healers first are often behind these late arrivals.

Mohammed is one of more than 300,000 children treated by MSF in Niger, in partnership with the Ministry of Public Health, between January and October 2019. As in other countries in the region, the main causes of death for children under five years old in Niger are malaria, respiratory tract infections, and diarrheas. Yet, it is estimated that malnutrition is an underlying contributing factor in nearly half of such deaths—and it severely hampers the development of children who survive.

A public health approach

In 2018, the government of Niger registered more than 2.75 million cases of malaria, mostly during the seasonal peak between July and October. More than 3,000 of these proved fatal. Children under the age of five were the worst-affected, accounting for half of the deaths. A country-wide survey conducted by national authorities in October and November 2018 revealed that prevalence of severe acute malnutrition reached a worrying level of 3.2 percent, higher than the emergency threshold of 2 percent.

“The good news is that we know the medical solutions to improve this situation,” said Rilia Bazil, MSF medical coordinator in Niger. “Nigerien health care has taken a number of positive steps since the introduction of ready-to-use therapeutic food. This includes more inclusive criteria to define malnutrition; progress on child feeding practices; home-based screening of potentially malnourished children measured using the innovative mid-upper arm circumference (MUAC) tape; simple, rapid diagnostic tests for malaria; seasonal malaria chemoprevention; and improvements to ambulatory and facility-based treatments.” Ultimately, an increased public health approach, with a strong community-based component, is helping reduce the prevalence and rates of mortality linked to malaria and malnutrition.

In Niger, health promotion and the national program for integrated community-based case management of childhood illnesses (iCCM) have become crucial instruments to deal with childhood diseases, especially in rural areas. The iCCM establishes a network of health workers chosen by their own communities, who are trained and equipped to diagnose and treat non-complicated diseases, thereby improving the chances of survival and full recovery of patients.

“Mini health facilities”—often a big tree, tent, or small hut—are used as staging posts for initial treatment of sick children, providing immediate diagnosis and care or referring them to a health center. In the Magaria district of Zinder and the Madarounfa district of Maradi, for example, 172 community health workers conducted 39,015 consultations between July and September 2019.

Hoping for the best, planning for the worst

“Prevention saves lives, as does bringing adequate treatment options closer to people in need,” said Dalil Mahamat Adji, MSF head of mission in Niger. “Childhood diseases need to be tackled in a multidisciplinary way.” To accomplish this, MSF teams strive to ensure that the most vulnerable girls and boys can reach free, high-quality health care in time for it to make a difference. “We need to hope for the best, but always plan for the worst, upscaling our support to prevent suffering and deaths linked to malaria and malnutrition.”

In order to prepare for the seasonal peak of malaria and malnutrition, MSF doubled or tripled its hospitalization capacity in the most-affected regions and strengthened community-based prevention and treatment of childhood diseases. This includes a wide range of activities, from awareness-raising on health and hygiene to community-based initiatives to support for seasonal malaria chemoprevention and vaccination campaigns to improve children’s protection against diseases.

Reducing the prevalence and mortality of childhood diseases requires improvements to the health sector, food security, education, and livelihoods in the most vulnerable regions. With other humanitarian needs on the rise because of conflict and insecurity in the region, all stakeholders must keep fighting to stop malaria and malnutrition from claiming lives, so all children can grow up in good health.  

MSF first worked in Niger in 1985. We now run projects in the Zinder, Maradi, Diffa, Tillabéry, Agadez, and Tahoua regions, with more than 1,660 year-round staff and an additional 360 employees during the seasonal malnutrition and malaria peak.

Our main objectives are reducing child mortality, improving the quality of pediatric and maternal care, helping survivors of violence and displacement, and assistiung both communities and people on the move. We also respond to disease outbreaks and support the Ministry of Public Health to improve immunization coverage against illnesses such as cholera, measles, and meningitis. In 2018, our teams treated more than 443,000 children affected by malaria, malnutrition, and other illnesses.

MSF’s medical research arm Epicentre has also been conducting field studies and surveys in the country since 2005, with the aim of improving the overall response to nutritional crises and epidemics.

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