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Doctors Without Borders: Undernutrition Is a Community Health Issue

A pilot project run by Doctors Without Borders is examining how effectively community health workers can plug gaps in addressing malnutrition, including limited knowledge about its symptoms and a lack of healthcare facilities.

Written by Andrew Green Published on Read time Approx. 5 minutes
A Doctor Without Borders health worker measures a child with a MUAC tape for symptoms of malnutrition at a health center in Chakradharpur, Jharkhand. NIKHIL ROSHAN

Communities don’t need to rely on hospitals to treat moderate cases of malnutrition, a year-old pilot project in rural India has found, but can instead utilize community-based health workers, who can both identify and treat cases and ease pressure on the overstretched health system.

The medical humanitarian group Doctors Without Borders introduced community management of malnutrition in Jharkhand last year. The Indian state has some of the highest rates of severe acute malnutrition in the world. More than 750 children have already been identified and received treatment through the program, according to the organization’s records.

Before the project, health officials there were confronting a number of challenges, including a lack of medical facilities in the state to treat the cases of malnutrition and a lack of understanding among parents about how to identify undernutrition. So Doctors Without Borders turned to community-based health workers, equipping them with both the knowledge to raise awareness about undernutrition, but also to identify and begin treatment for children who show early signs of acute malnutrition, thus relieving the burden on the health system.

Malnutrition Deeply spoke to Dr. Amit Harshana, the deputy medical coordinator for Doctors Without Borders in India about what he has learned during the first year of the project.

Treating Severe Acute Malnutrition in Chakradharpur block of Jha

A mother looks on as her child is measured with a MUAC tape for symptoms of malnutrition at Pusalota health center. (NIKHIL ROSHAN)

Malnutrition Deeply: Can you walk us through the thinking behind introducing this pilot project?

Dr. Amit Harshana: If you’re talking about India, the burden of acute malnutrition is quite high. Looking at the burden of malnutrition, the treatment centers that are at the district level or sub-district level, which are usually the nutritional rehabilitation centers, are quite few in number. If you want to treat all these children, probably it will take another 10, 15 years for us to treat all these children.

We need to have a decentralized model. From the technical aspect, all these seriously acute malnourished children they do not need admission in a medical setting. Overall, if you look at the percentages, there are 10 to 15 percent of the kids that actually need intensive medical attention for which they need to be admitted in a typical medical setting. What happens to these remaining 80 to 85 percent of the children?

We are trying to develop this community-based management of malnutrition. In India, usually you have got grassroots – or what we call them is – frontline health workers. These frontline health workers, those who are working at the community level, should be strengthened so they can identify these same children. The remaining 80 to 85 percent of the children should be treated in the community itself by these frontline health workers. This is the basic concept of community-based management of malnutrition: Having a decentralized approach where we talk about giving treatment and also the preventive measures.

Malnutrition Deeply: What preventive steps are you teaching?

Harshana: We are teaching the community about the local foods, about the other variables for malnutrition, for example, breast feeding, antenatal nutrition and care for pregnant mothers, adolescent nutrition. All this comes as a package. Giving all these preventive aspects and the training for all the preventive [approaches] to the grassroots health workers and also the community.

We are training the grassroots health workers. What we are trying to do is we’ll be training them on how do you pick [undernourished children] from the community. What are the tools to identify or screen the community to help these children?

Malnutrition Deeply: When you were doing the training in the communities, what was their reaction? Did parents have an understanding of what malnutrition was beforehand?

Harshana: When we talk about malnutrition, it is not a disease for them. That’s the biggest challenge for the community. They don’t consider this as a disease. Fifty percent of them will be considering it as weakness for which you do not actually need medical attention. It’s like it’s okay to have a weak child in the community. The mother is also weak. It is very difficult for her to understand that this weakness is a problem. Right? In a poor setting, usually, weakness is not something for which they will grab attention and they will take this child to a medical setting, unless you’re having some pneumonia, diarrhea or any of the other serious complications.

The problem is, it is not a disease, for example, which is showing signs and symptoms. If you’re having pneumonia, the mother can see that there’s something happening to the child’s body and then she freaks out and she takes the child to some practitioner.

For malnutrition, if you’re weak, it’s not a problem for them. We are making them understand that if you do something at this stage, probably your child will not [get worse].

Also, what do you do when the child is at the next level? We are doing a lot of community engagement, a lot of awareness campaigns just to make them understand the harm you’re doing to the child. It is the most challenging part, but still, in one year or so, I’ve seen some changes.

Malnutrition Deeply: Can you talk more about the impact that you’re seeing?

Harshana: [At the start of the project], we were having around 3 to 4 percent prevalence of severely malnourished children. Looking at that number, what we were expecting was, in a year, we should get around 1,000 children [in need of treatment]. This is what we were expecting. From June we started, and from the [beginning], it was a great number that we received. We have already received around 750 children, and we have already treated them. That’s a good number. And we were expecting around 800–900 in a year. So in a year, we’re almost there. For the first year of the project, it is a pretty good number.

There’s negatives: 20–30 percent defaulting, and those who are not responding to treatment, and all those things. That is very much expected when you start a community-based intervention, because it is not your controlled hospital setting where you do whatever you do.

But slowly, slowly, we are also working on that case by case, mother by mother, community by community. We’re going deep into the analysis and trying to find out how to change the behavior. All those things will probably, I hope, in the next year, be the same, but the percentage of cured will go really high.


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