Treating malnutrition is a medical imperative, yet the world's response is falling desperately short. Dr. Tido von Schoen-Angerer, director of Médecins Sans Frontières’ Campaign for Access to Essential Medicines, looks at our response to another recent medical imperative – the decision, in the face of adversity and sometimes even commonly accepted orthodoxy, to treat patients for HIV/AIDS – and asks whether there is not something that can be learnt. How can we overcome the ambition gap in treating malnutrition?

When I was a field doctor working with MSF in Thailand in 2000, MSF’s response to the HIV/AIDS pandemic was one based on a simple medical decision: faced with the urgency of millions dying, the only acceptable response was to treat. A decision simple to articulate, perhaps, but complex in its ramifications: antiretrovirals could help extend millions of lives, but treating the disease was simply deemed unfeasible in developing countries. Too expensive, too high tech, and too difficult: better to focus on preventing new infections, on distribution of condoms, on information and education, on behaviour change. MSF with others sought to challenge that ambition gap, that lack of will – and eight years later, with about 140,000 patients on treatment in our programmes, we have shown the successes of that decision.

Today, the world’s response to malnutrition is at a similar crossroads, and presents a similar ambition gap. The stakes are just as high: every year, malnutrition contributes to the deaths of five million children under the age of five.

In many ways, we’re in a better position than with HIV/AIDS in 2000, because a basic framework for addressing malnutrition is in place. New successful strategies, outlined in the Joint Statement on Community-based Management of Severe Acute Malnutrition, have been endorsed by United Nations agencies as a blueprint for treatment – they enable programmes to reach patients on a scale previously unheard of. Ready-to-use foods make it possible to treat the children most at risk of dying, giving excellent results in MSF projects and beyond. In 2006, in Maradi in southern Niger, MSF was able to treat 65,000 children – of whom 7.5 percent were severely malnourished – and over 90 percent of the children recovered.

The potential for great change is there. However, there is little possibility for making this change as long as major donors, and United Nations agencies such as UNICEF and the World Food Programme (WFP), continue to approve ineffective food aid for children. For the most part, infants in areas of conflict around the world are still being given inadequate food.

Current food aid consists mainly of corn or wheat/soy porridge recipes that fall far short of the mark in terms of nutritional quality. The levels of vitamins and minerals are inappropriate for young children and it is hard for them to absorb essential minerals, which are vital to childhood development and survival. The stark truth is that many food aid programmes are giving malnourished children food that is difficult to digest.

Maybe the source of the ambition gap, as it was for HIV/AIDS, is the cost. New, specialised products which contain important animal source foods are expensive, and will require international funding. However, there are those who say: it’s too expensive, too high tech, too complicated. We’ve all heard this before.

But experience has shown, including with HIV/AIDS, that when there is political will, financial resources are sure to follow. And considering the exceptional results achieved and the potential to save lives, can we allow our response to a medical imperative to be limited by assumptions about financial feasibility?

Undoubtedly, other challenges remain. Strategies to treat severe acute malnutrition that have proven successful in Africa must be adapted for Asian settings. New products, new ways of delivering essential nutrients, such as sprinkles or spreads, must be developed to suit local tastes and imperatives. The vast potential of local production needs to be tapped and the cost of ready-to-use food must come down further.

This will require ambition. At the moment, only around 5 to 7 percent of severely malnourished children are able to access the treatment they need. Ultimately, implementation of a community-based strategy that delivers essential nutrients to children under the age of three will mean the difference between life and death for millions of children.

Dr. Tido von Schoen-Angerer

Director of Médecins Sans Frontières’ Campaign for Access to Essential Medicines

(MSF via China.org.cn December 3, 2008)