POVERTY: NIGER: Malian refugees flee to hunger zone

GAOUDEL/TILLABERI, 27 February 2012 (IRIN)

 Photo: Jaspreet Kindra/IRIN
For each day over the past three weeks at least 187 Malians fleeing fighting in their country have sought refuge in Gaoudel village, Niger

No babies cry and the children are not even curious about the presence of strangers. “It is hunger and they are shy - they are not used to strangers,” explained one of the mothers, who is among a couple of thousand Malians who have crossed into southwestern Niger and sought refuge in the windswept village of Gaoudel, Ayorou District, after fleeing clashes between Malian government troops and Tuareg rebels.
At least 10 children are among those sheltering in silence from the relentless sun under scraps of fabric tied to sticks in the ground. They are 10km from the Malian border.
During their two-day desert journey here they have had little to eat. Many had no time to pack anything and fled with just the clothes they were wearing. Some managed to come with their animals.
The host population - Tuaregs like the refugees - share their scarce food and water, but are stretched: The refugees now outnumber the villagers.
“They are the same people as us - black Tuaregs. Some are relatives, separated only by the border. We are all fighting drought and do not have enough food,” said Gaoudel village chief Echec Ahmad.
Their only water source - an uncovered well - will run dry in two months, he said, adding that repeated droughts had decimated their herds and that they depended on the few green beans they had managed to grow in a dried-up stream.
Some of the Malian men have arrived with animals, hoping to sell them in Ayorou town (30km away) in Niger’s Tillaberi Region, one of the worst-affected by drought in Niger. But the livestock trade in Ayorou is in poor shape. “There are a lot of animals in the market but not enough buyers,” said Biga Beidari with the UN Office for the Coordination of Humanitarian Affairs (OCHA) in Tillaberi.
The closure of Niger’s border with Nigeria, after attempts by militant group Boko Haram to set up a base in the drought-stricken country, has had an impact on the local economy: The absence of Nigerian livestock buyers in local markets seems to have hit pastoralists across the region hard.
“If I sell three goats, I will be able to buy only 100kg of millet - enough for my family [two wives and seven children] to eat for 10 days,” said Mohammed Warimagalis, a Malian refugee and pastoralist who has picked up English on his travels. He arrived in Niger two days ago with 30 goats, which he fears will help his family survive for only about three months.

No jobs, little food
The refugees are our neighbours and they need assistance now
Most towns in the region are awash with people from food-scarce areas looking for work. An assessment by French NGO Agency for Technical Cooperation and Development (ACTED) found 94 percent of the villages in the districts of Tillaberi, Ouallam and Filingue do not have enough food; 89 percent of the population, or more than a million people, are affected.
The Mali clashes come at an unfortunate time, said Oumarou Sadou, prefect of Tillaberi. “But they [the refugees] are our neighbours and they need assistance now.”
Fighting in eastern Mali has spread to areas closer to the northwestern corner of the Tillaberi Region, prompting an influx of Malians into this part of Niger. Some aid workers fear the numbers could rise, as most arriving up to now had taken pre-emptive action. "We left as we heard the clashes were going to begin," said Warimagalis.
Plan Niger, an NGO operating in the area, says the number of refugees has been increasing rapidly and more resources are urgently needed to support them.
Plan Niger spokesperson Maman Farouk said that over the past five days another 932 refugees had been recorded in Gaoudel. The NGO has been registering Malian refugee children in local schools. They need more food, tents, medicine, bed nets, blankets and mats. They also hope to drill wells to support the host community with water.
Based on local authority figures, IRIN estimates at least 187 Malians sought refuge in Gaoudel village every day in the past three weeks.
Thousands of Malian refugees have trekked across the border to small towns and villages like Mangaizé, Chinégodar, Koutoubou and Yassan in Tillaberi, since mid-January, according to the Malian Ministry of Foreign Affairs.
Most of them - more than 9,000 - ended up in Chinégodar, which is usually home to 1,500 people. However, the number arriving here, where the Niger government and aid agencies have been providing support, has levelled off, said Benoit Kayembe, head of Médecins Sans Frontières Swiss in Niger.
Fighting between the Tuareg liberation movement MNLA (Mouvement National de Liberation de l’Azawad) and government forces resumed in Mali in mid-January, after the Tuareg rebellion was officially declared over by the government in 2009.
http://www.irinnews.org/report.aspx?reportID=94971

MALNUTRITION: Ethopia: The Crisis Continues: Dollo Ado to Open its Fifth Camp

19 November 2011 - 5:01pm By Sam Piranty Share
 
Photo Credit: Sam Piranty Dollo Ado, Ethiopia:

An extremely high level of malnutrition is apparent in Ethiopia's Dollo Ado refugee camps, which continue to expand in response to the on-going crisis in the Horn of Africa.
Malnutrition and overcrowding remain a real cause for concern in Dollo Ado, a collection of refugee camps in south eastern Ethiopia. The four camps at Dollo Ado are already at capacity with a total polulation of 137,000. It is set to open a fifth camp this weekend, Bur Amino. Though yet unpublished, recent results from a survey conducted in both Kobe and Hilaweyn camps have revealed extremely high malnutrition rates that surpass the emergency threshold of 15%. The issue is complicated by the fact that there is actually a good supply of food available. The World Food Programme (WFP), who are facilitating the General Food Distribution in the camps are providing staples such as cereal, pulses, Corn Soya Blend (CSB), oil, salt and sugar with other NGOs supplying further complimentary foods.
With the Ethiopian government and Médecins Sans Frontières treating those diagnosed with severe acute malnutrition, the WFP aims to tackle those with moderate acute malnutrition. If the programme is followed correctly patients can recover within 60-90 days. The fulcrum around which the programme revolves consists of a premix made up of CSB plus, oil and sugar. Every week, this is given to the mother of each household to distribute to their family. It is a vital part of the recovery process and Giorgia Testolin, Head of Refugee Section for the WFP in Ethiopia, believes that with this already available there should not be such widespread malnutrition across the four camps in Dollo Ado and claims ‘there is something wrong at the household level of the consumption of food’. The precise problem is yet to emerge although it has been suggested that it could be do with the sale of some of the provisions refugees receive. Many sell some of the food they receive in order to purchase other food items and commodities both within the camps and the host communities. However, Testolin believes that the premix is not sold and that ‘we expect refugees to sell part of the food to buy what is not in the food basket provided by WFP. Such as milk, meat, tomatoes and vegetables. They cannot have a standard diet every day’.
The problem of malnutrition does not therefore seem to be merely economic but rather manifests itself in a misconception of the nutritional significance of things like the premix and Plumpynut, a peanut based paste. Testolin believes that it is vital the refugee community develop a greater understanding of the importance of the consumption of the premix but suggests that this will take time for ‘it’s a cultural and behavioural change that cannot be reached in a couple of months... If you don't understand that this food is the right food for you, because as a pastoralist you may be used to camel milk and meat and you don't have that food which you believe is the food which will improve the health of your child. It becomes very difficult for the messages [outlining the importance of things like the premix] to pass through to the mothers and fathers...a lot more needs to be done in a community based approach through outreach workers.’ An assessment is due to be undertaken by the WFP, the UN Refugee Agency (UNHCR) and the Administration for Refugees and Returnee Affairs (ARRA) in December this year to try and both pinpoint the problem and develop a more comprehensive solution.
Overcrowding is also a major issue in the camps in Dollo Ado. Over seven thousand refugees are awaiting relocation in the transit centre with the opening of Bur Amino having been delayed for almost a month and the four remaining camps already at full capacity. The delay has been put down to a number of different factors. Previously, when the fourth camp opened early there were numerous problems with sanitation and services. It is therefore vital that because of the recent rains and overcrowding which increase the probability of the spreading of disease, that the fifth camp is completely finished before those in the transit centre move in. Furthermore, the soil around the site is particularly difficult to excavate and with the torrential rainfall taking the airstrip out of service and blocking the roads into the camps, many of the tools needed have been difficult to co-ordinate. However, Bur Amino is due to open this weekend, which will be a welcome relief for thousands of individuals and families. This could not have come at a more important time, in light of the recent intervention in Somalia by the Kenyan military and the tightening of border controls between Kenya and Somalia. Whereas before many refugees have suggested that Al Shabaab had blocked the route to Ethiopia and directed them toward Kenya, now those looking to flee Somalia will focus on reaching Dollo Ado rather than Dadaab.
http://thinkafricapress.com/ethiopia/crisis-continues-dollo-ado-open-its-fifth-camp

MALNUTRITION: Somalia: The Vital Statistics of Hunger

July19, 2011

JOHANNESBURG (IRIN) - Louise Masese-Mwirigi, an analyst recording nutrition data in southern Somalia with her team, have on occasion had to turn away from a village because the local authority that consented to the survey a week ago is no longer in charge or may have changed their minds when they arrive. Fighting between the government, its allies and various armed groups in parts of Somalia has severely restricted humanitarian space.
“The situation is uncertain in Somalia and access is a problem - especially in the last two years in central and southern Somalia,” said Masese-Mwirigi, who works for the UN Food and Agriculture Organization’s Food Security and Nutritional Analysis Unit (FSNAU) for Somalia.
Armed with an electronic weighing scale and a metre-long board to measure the height of children, Masese-Mwirigi and her team, led by Mohamed Moalim, along with Action Contre la Faim (ACF), a food relief NGO, have carried out a survey in the Mogadishu region, where the capital is located.
The survey is the first in seven years. “It took a month of planning… we could access six districts but had to let go of the remaining three because of security concerns.”
A rapid assessment by FSNAU in Mogadishu in December 2010 picked up high levels of malnutrition based on the measurement of the middle upper arm circumference (MUAC) - a quick, easy and cheap approximate measure of malnutrition in children younger than five years. “We felt we needed more information through a comprehensive nutrition survey, given the rains had performed poorly and the MUAC results were indicating high levels of malnutrition in the town.”
The MUAC measurement uses a long strip of plastic with a series of colour-bands that is put around a child’s bare upper arm. The colours show the level of malnutrition: green indicates a 135mm circumference, which is normal; yellow - 125mm to 134mm - shows a risk of malnutrition; orange - 110mm-124mm means moderate malnutrition; red, for measurements less than 110mm, is an indication of severe malnutrition and risk of death.
In the past two years FSNAU have had to depend entirely on MUAC in parts of the conflict-hit areas. “It is less resource-intensive, and quick and ideal for emergency situations, but ideally we would like a more thorough survey,” Masese-Mwirigi said.

Detailed data
A thorough survey would take into account four variables - age, weight, height and gender - as well as the MUAC. Crude mortality rate (usually measured in deaths per 10,000 people per day in emergency situations), rate of disease prevalence, child care and feeding practices, household food security, and water and sanitation indicators, are also taken into account to understand the overall nutrition situation.
When two of the anthropometric variables are used together they are called an index. Three indices are commonly used to assess the nutritional status of children: weight for age (WFA), height for age (HFA) and weight for height (WFH).
These indices are then compared to a reference standard to get a sense of the severity and distribution of the nutritional problem in a country. The WFA of a child compared to a reference population will tell if the child is normal, overweight or underweight. HFA indicates whether the child’s height is normal for his or her age. If the child is not as tall as expected then he or she is stunted, reflecting a long-term, chronic problem - stunting is a good indicator of chronic malnutrition.
WFH is commonly used in acute emergencies to determine the scale of the crisis. It is often used when the child’s age is not known, and in countries like Somalia, where hardly any public records of births and deaths exist. WFH is regarded as a good indicator of acute or short-term exposure to a negative environment, such as a drought, as it reflects recent weight loss or gain. WFH is a measure of acute malnutrition.

Room for error
With so many measurements involved there is always a lot of room for error.
For instance a baby can often be not held properly to measure its length, or perhaps the child is not standing straight. Aid organisations are constantly trying to improve the skills of surveyors involved in taking measurements by organising training workshops periodically.
Determining the correct age can also be problematic. “We use the calendar of events to accurately determine a child’s age,” explained Masese-Mwirigi. Events like major natural disasters or elections can indicate when a child was born.
The other contentious issue in measuring malnutrition is what is considered average. The World Health Organization (WHO) provides a reference of growth standards, against which surveys calculate their deviations from the norm.
Yet the WHO growth standards might not be the norm for a particular ethnic population that is naturally long-limbed, like Kenya’s Maasai, or short-limbed, like the Gurkhas of Nepal. Even though the WHO standards were recently updated to better reflect human genetic diversity some experts feel country- or region-specific growth standards should be developed.
Prominent experts like Mark Myatt, Senior Research Fellow at the Division of Epidemiology, of the Institute of Ophthalmology, University College, London, feel MUAC is a much more accurate measure.
But that is not all. There are different scales of malnutrition. For individuals malnutrition can be moderate acute or severe acute.
To work out levels of malnutrition, WFA, HFA and WFH measurements are used to calculate and classify using what is known as the “percentage of the median” and “Z-scores”.
For instance, in expressing the WFH as a “percentage of the median”, a child’s weight is divided by the average weight for a child of that height, as provided in the WHO growth standards, and then multiplied by 100 percent. Fortunately, there is computer software that does the calculation.
The “Z-score” represents the difference between the observed weight and the median weight of the reference population, expressed in standard deviation units. When the percentage of the median is less than 70 percent, and the Z-score is less than -3, or oedema is present, the child is said to be suffering from severe acute malnutrition.

GAM or SAM?
Populations are described as severe acute or global acute. “Global acute malnutrition (GAM) refers to the total cases of moderate acute and severe acute malnutrition (SAM) in a population,” Médecins Sans Frontières (MSF), the medical NGO, notes in their useful manual, A Beginner’s Guide to Malnutrition.
GAM is calculated with the Z-score defined as a weight-for-height index less than -2 standard deviations from the mean weight of a reference population of children of the same height.
A GAM value of more than 10 percent generally identifies an emergency. Commonly used thresholds for GAM are less than five percent (acceptable), between five and just under 10 percent (poor), between 10 percent and under 15 percent (serious), while anything more is critical.
Clinical signs such as bilateral oedema - swelling in the feet, legs or face caused by an extreme shortage of protein - are a separate indicator of severe malnutrition in children.
“We recorded a GAM rate of 15.2 percent for Mogadishu in our survey,” said Masese-Mwirigi. In Somalia the FSNAU has been recording GAM rates of 15 percent and above for a long time, GAM rates of over 15- 20 percent indicate a critical nutrition situation, while rates over 20 percent are seen as very critical. The GAM rates reported in Mogadishu town are high, also given that there are a large number of feeding interventions in the town.

Prices of the staple grains - maize and sorghum - have gone up by between 52 and 95 percent in most markets. FSNAU reports that in some areas prices have doubled and even tripled since 2010.
In 2011 the major rainy season began late and was poorly distributed across time and place in southern Somalia - the second bad season consecutively, as the first harvests in January failed.
A smaller cereals harvest, low stocks and poor access because of continued conflict to Bakara, the main market in Mogadishu, have made basic foodstuffs harder to get and more expensive.
http://harowo.com/2011/07/19/somalia-the-vital-statistics-of-hunger/

MALNUTRITION: Somalia: Malnutrition crisis

15/07/2011

Dr Hussein Sheikh Qassim works in the Médecins Sans Frontières hospital in Marere, southern Somalia. He spoke to us by phone at 1pm on 15 July.
“In Marere, the situation is extremely dire. This is the only hospital in this part of Somalia. There are no other clinics – not even mobile clinics – anywhere near here. People are coming here from all over the country. Word spreads.
"The malnutrition ward is beyond full..."


A one-year-old Somali girl is given emergency treatment at an MSF hospital across the border in Kenya.

©AP/Press Association Images

"Recently the numbers have gone through the roof. Even on our quiet days, we are seeing twice as many people as we did on busy days before the drought.
"The hospital is absolutely full of patients. Some are sick, others just need something to eat.
"The malnutrition ward is beyond full – of young children, most of them too weak even to eat, so we have to feed them through tubes.
"Some of these children had to walk for over 600 km to get here because their parents couldn’t afford transport and were too weak to carry them on their backs. There is an ongoing civil war in many parts of the country, with some towns and villages changing hands on a daily basis. These are dangerous areas and it is not safe to travel. But still the people come.
"We’ve already admitted 151 children today..."



Asad (not his real name) was extremely ill when his mother brought him to the MSF Marere hospital. © MSF







"Those who are lucky and are still on their feet are admitted as outpatients – 300 yesterday, 400 last Friday. But lots of children have to go straight to the inpatient feeding centre. It’s only lunchtime and we’ve already admitted 151 children today.
"Recently a mother and her husband brought us a two-year-old boy called Yusuf. He was nothing more than bones and skin. He was too weak even to breathe. The family were pastoralists and all their animals had died.
"They told me the child had diarrhoea and couldn’t eat. He was in such a bad way you had to listen to his heartbeat through a stethoscope to tell he was still alive. His parents had given up on him – they believed he had no chance of survival and they wanted to leave so they could look after their other children.
"The father went off to look after the other children while we convinced the mother not to give up.
"His mother’s face suddenly lit up..."



Asad (not his real name) was discharged home in good health condition after 43 days of hospital treatment

© MSF






"We put the child in our intensive care unit where we resuscitated him for two hours, until finally he opened his eyes. Then we fed him specialised milk and food through a tube. After 24 hours he started moving his limbs. It was at that moment that his mother’s face suddenly lit up – you could see that she had hope again.
"After one week Yusuf didn’t need to be fed through a tube any longer. He could drink milk on his own, and he could say 'mum', and smile back if you called his name. Within 10 days his weight had more than tripled.
"After three weeks in our hospital, Yusuf was playing around with the other children. His father came to collect him and he was beyond happiness – he didn’t stop thanking MSF until he’d left the hospital.
"As a Somali myself, I can say that if MSF were not here, we would be like a boat that has run out of fuel in the middle of the Indian Ocean. Without MSF’s help, thousands would have died.
"Somalia needs your help now more than at any other time. MSF saves countless lives and, with your help, will continue to save many more. Thank you.”
http://www.msf.org.uk/articledetail.aspx?fId=Marere_Somalia_20110715

MALNUTRITION: Horn of Africa: MSF acts on malnutrition and drought

11 Jul 2011
The announcement by one of the main armed factions in Somalia, Al Shabaab, that foreign relief organisations would be welcomed in territories under their control has raised hopes for a desperately-needed scale-up of assistance inside the country.
“MSF has been working continuously in Somalia for over two decades running large-scale medical programs,” said Joe Belliveau, MSF operational manager.
“We have managed to maintain our programmes under Al-Shabaab, but restrictions on supplies and international support staff have prevented us from scaling up further. We hope that the Al-Shabaab statement leads to a lifting of these restrictions.”

Refugees
MSF teams are fully stretched in various locations inside Somalia, as well as assisting exhausted refugees crossing Somalia’s borders into Ethiopia and Kenya
“Most of our therapeutic feeding programs in Somalia are running over capacity with more than 3,400 children currently enrolled in our nutritional programs. We are running emergency nutritional projects in several locations in the Lower Juba valley region, in Galgaduud, Mudug, Lower Shabelle, and Bay region," said Mr Belliveau.
"The past weeks we’ve seen a sharp rise in cases with some people travelling hundreds of kilometres to get access to health care and treatment for their malnourished children,” he added.

Drought
Over the past year, the eastern Horn of Africa has experienced two consecutive poor rainy seasons, resulting in one of the driest years in decades in many pastoral zones.
The impact of the drought has been exacerbated by high local cereal prices, excess livestock mortality, conflict and restricted humanitarian access in some areas.
Large parts of Somalia have been ravaged by civil war for over 20 years, and people displaced have great difficulties accessing the few places where food aid and health care is extended.

MSF treatment centre
'Ader Mohammud, a 19-year-old mother of one, travelled around 250 km to bring her weakened child to the MSF treatment centre in Galcaayo. For daughter Najmo, 11 months old, the long journey had almost been too late and too long.
“I could not afford the transport cost, I have no support in Galcayo; I survive only with what other patients and caretakers give me,” says ‘Ader.
She does not know how she will go back home, she believes that selling her exit ration to pay the transport will be the only solution.

Somalia, Kenya and Ethiopia
The situation is equally dramatic in other areas in Somalia.
“In the town of Marere [southern Somalia] we noted a sharp increase in cases of severe malnourishment amongst people coming from all over the Juba valley,” says Joe Belliveau. “The majority of the hospital beds in Marere are currently occupied by malnourished children in need of intensive care, and additional staff has been recruited to assist.”
Meanwhile, tens of thousands of Somalis have been fleeing to Kenya and Ethiopia in search of assistance.

Dadaab camp
The sprawling Dadaab refugee camp in eastern Kenya has seen a rapid growth of new arrivals.
An assessment on the outskirts of one of Dadaab’s camp sites, MSF teams found extremely high malnutrition rates amongst the new arrivals.
As a consequence, MSF admitted 320 children to their In-patient therapeutic feeding centre in June alone – three times as many as in the same month last year. The survey also found that 43.3 percent of children aged five to 10 are malnourished.

New refugees and food
In addition, MSF is very concerned about delays in the assistance provided to the newly-arrived refugees. Since the 30th June, refugees have received food for 15 days upon arrival, but are told to wait as long as 40 days for the second food ration.
“Families arriving in Dadaab are seeking a safe haven, and it is unacceptable that they should be made to wait this long to receive even the most basic form of assistance, food and water,” said Emilie Castaigner, acting MSF head of mission in Kenya.
In Dolo Ado, in south-eastern Ethiopia, around 1,400 refugees cross the border every day, 2,700 on June 28th alone. Dolo Ado already hosts almost 100,000 refugees in camps originally designed for 45,000 people.

Transit camps
On arrival the transit camp in Ethiopia, before reaching the camps where they are reallocated, 37 percent of children under five years old screened by MSF are malnourished. MSF is currently treating more than 6,800 children in these nutritional programmes.
“MSF is increasing its capacity [in these camps] but the operational limits are being reached," explained Alfonso Verdú, head of MSF operations in Ethiopia."The engagement of other organisations to the nutritional crisis is essential while the present ones should uphold their responsibilities to avoid the deaths of many vulnerable people."
--------------------------------------------------------------------------------
MSF has worked continuously in Somalia since 1991 and currently provides free medical care in eight regions of southern Somalia. Over 1,300 Somali staff, supported by approximately 100 staff in Nairobi, provide free primary healthcare, malnutrition treatment, health care and support to displaced people, surgery, water and relief supply distributions.
MSF does not accept any government funding for its projects in Somalia, all its funding comes from private donors.
http://www.trust.org/alertnet/news/msf-acts-on-malnutrition-and-drought-in-horn-of-africa

MALNUTRITION: Somalia: MSF: "The Situation Is Extremely Dire"

July 19, 2011
Dr. Hussein Sheikh Qassim is the Medical Coordinator in the Doctors Without Borders/Médecins Sans Frontières (MSF) hospital in Marere, in southern Somalia, where violence and drought are driving people from their homes in search of medical care and shelter. On July 15, he was reached on the phone and gave the following report about the situation in the area:
“In Marere, the situation is extremely dire. This is the only hospital in this part of Somalia. There are not any other clinics, not even mobile clinics, anywhere near here. People are coming here from all over the country. Word spreads.
Recently, the numbers have gone through the roof. Even on our quiet days, we are seeing twice as many people as we did on busy days before the drought. The hospital is absolutely full of patients. Some are sick, others just need something to eat. The malnutrition ward is beyond full of young children, most of them too weak even to eat, so we have to feed them through tubes.
Some of these children had to walk for over 600 kilometers [360 miles] to get here because their parents couldn’t afford transport and were too weak to carry them on their backs. There is an ongoing civil war in many parts of the country, with some towns and villages changing hands on a daily basis. These are dangerous areas and it is not safe to travel. But still the people come.
Those who are lucky and are still on their feet are admitted as outpatients, 300 yesterday, 400 last Friday. But lots of children have to go straight to the inpatient feeding center. It’s only lunchtime, and we’ve already admitted 151 children today.
Recently, a mother and her husband brought us a two-year-old boy called Yusuf. He was nothing more than bones and skin. He was too weak even to breathe. The family were pastoralists and all their animals had died. They told me the child had diarrhea and couldn’t eat. He was in such a bad way you had to listen to his heartbeat through a stethoscope to tell he was still alive. His parents had given up on him. They believed he had no chance of survival and they wanted to leave so they could look after their other children. The father went off to look after the other children while we convinced the mother not to give up.
We put the child in our intensive care unit where we resuscitated him for two hours, until finally he opened his eyes. Then we fed him specialized milk and food through a tube. After 24 hours he started moving his limbs. It was at that moment that his mother’s face suddenly lit up. You could see that she had hope again.
After one week, Yusuf didn’t need to be fed through a tube any longer. He could drink milk on his own, and he could say, 'Mum,' and smile back if you called his name. Within 10 days, his weight had more than tripled.
After three weeks in our hospital, Yusuf was playing around with the other children. He father came to collect him and he was beyond happiness. He didn’t stop thanking MSF until he’d left the hospital.
As a Somali myself, I can say that if MSF was not here, we would be like a boat that has run out of fuel in the middle of the Indian Ocean. Without MSF’s help, thousands would have died. Somalia needs your help now more than at any other time. MSF saves countless lives and, with your help, will continue to save many more. Thank you.”
http://www.doctorswithoutborders.org/news/article.cfm?id=5453&cat=voice-from-the-field&utm_source=feedburner&utm_medium=feed&utm_campaign=Feed%3A+DoctorsWithoutBordersNews+%28Doctors+Without+Borders%2FM%C3%A9decins+Sans+Fronti%C3%A8res+News+Updates%29&utm_content=Google+Reader

POVERTY: PAKISTAN: Collapsing medical facilities in conflict-ridden northwest

PESHAWAR, 21 July 2011 (IRIN)

 Photo: Kamila Hyat/IRIN

Hamida who suffers heart trouble worries about the future of her children

 For the last three years or so, doctors and nurses at the sprawling Lady Reading Hospital in the northwestern Pakistan city of Peshawar have been especially busy.

The hospital, one of the largest in the country, treats people across Khyber Pakhtoonkhwa Province (KP), but lately demands on it have grown.
“Since the conflict began in the tribal areas and elsewhere, around three years ago, we have a 20-25 percent increase in patient load. We now see 5,500-6,000 patients daily in the outpatient and emergency departments. I cannot give a precise figure but there were significantly fewer patients previously,” hospital chief executive Hamid Afridi told IRIN.
He agreed one reason for this was the collapse of medical facilities as a result of fighting in many areas.
“There are simply no doctors, and especially no female doctors, left in South Waziristan [one of the tribal agencies in northwestern Pakistan] - not even in the principal city, Wana. Most have got jobs in other places and moved away since the conflict began there,” Haroon Wazir, 25, told IRIN in a waiting area at Lady Reading.
He described a harrowing journey, over rough roads, he had made with his six-month pregnant, and sick, wife. “We travelled nearly 400km [from the tribal agency on the Pakistan-Afghan border] over two days in my brother’s van. We found a female doctor along the way but she said my wife, who is only 18 and pregnant for the first time, must be brought here, to a big hospital. The doctors are trying to save her and our baby.”The situation is especially difficult for women in conflict areas, who are often reluctant to see male doctors. Many refuse to do so altogether.
Women doctors threatened
The Taliban’s discouragement of women in employment has meant women doctors and nurses have often fled areas under militant control, or stopped working. Those who refused to do so have sometimes suffered terrible punishment, as happened to Shahida Bibi, a “lady health visitor” working under a government scheme in the small town of Shabqadar in the Charsadda District of KP, close to the Mohmand tribal agency, after it was taken over by the Taliban between 2008 and 2009. Despite threats she refused to quit her work.
“Shahida lived in the bazaar area. She was kidnapped by the Taliban. And after a couple of days her mutilated body was found under the Subhan Khwar bridge, near the Shabqadar bazaar. Her crime was that she worked,” Sher Ali, president of the Shabqadar Press Club, told the media.
Given such reports, it is understandable why women who can offer medical help are reluctant to return to work even in areas that have been freed of militants, such as Swat Valley in KP, where a military offensive drove out militants in the middle of 2009, allowing displaced people to return.
“Things are much better now. Many of us no longer wear burkas but just our traditional shawls. However, even though I am a qualified doctor I remain fearful of resuming work - though I feel very guilty because I see all around me women and children who need help. Not all can afford to travel elsewhere for assistance,” said Asma Khan, in Mingora, the main city in Swat. She had received threats for working during the Taliban insurgency.
Among those who need help are women like Hamida, who has heart problems. “We cannot afford to go elsewhere for medical help. Good women doctors are hard to find in Mingora, and my husband refuses to let me see a male doctor,” she told IRIN.”I often fear for the future of my children,” she said.

Kurram
Things are tougher still in areas like the Kurram Agency where conflict has continued since 2007 and has recently intensified.
Humanitarian agencies, since the conflict began in earnest in 2008, have also expressed growing concern over the situation and the lack of access to health care.
Médicins Sans Frontières stated in a recent report: “Sectarian violence in Kurram Agency, one of seven agencies in FATA [Federally Administered Tribal Areas], has meant that providing assistance in the towns of Alizai and Sadda is increasingly difficult. Sectarian tensions are reaching new levels against the backdrop of fighting.”

“We get men, women and children from all over the tribal belt and even from Afghanistan coming to us to seek the medical help they cannot get at home,” Lady Reading Hospital’s Afridi said.

 


http://www.irinnews.org/report.aspx?reportID=93286

TUBERCULOSIS: a disease of the poor

Kristin Palitza : 6.07.2011
The prices of medicines for DR-TB are rising around the world.

Access to treatment for drug-resistant tuberculosis (DR-TB, its acronym in English) remains compromised, especially in developing countries of the South, because very few pharmaceutical companies make quality drugs. In addition, the lack of competition has driven up the prices of drugs.

In the last decade, about five million people worldwide have developed the DR-TB. But a "shockingly low number" of patients (less than one percent) have access to appropriate treatment, according to Medecins Sans Frontieres (MSF).
About 1.5 million patients died in the past 10 years. The situation is particularly acute in poor countries with high numbers of HIV infections (human immunodeficiency virus, which causes AIDS), particularly where antiretroviral treatments are inadequate. South Africa is one of them.
One of the main barriers to treatment is the limited availability and high cost of quality medicines to treat DR-TB. For some drugs, there is only one manufacturer of assured quality or a single source for the necessary active ingredient.
"There is little investment in research and development of drugs against tuberculosis because it is a disease of the poor, and therefore a lucrative market doesn't exist for the pharmaceutical industry," said the office coordinator for MSF South Africa, Eric Goemaere.
 This has pushed up prices of most drugs for DR-TB. Treatment can cost a patient $9,000, according to MSF, almost 475 times more than the common treatment of tuberculosis.
Costs have increased further in recent years. "While drug prices usually fall with higher demand, in the case of drugs against drug resistant TB, they grow, some up to 600 or 900 percent. That is simply wrong," said Goemaere, who heads a project of treatment for HIV and tuberculosis in Khayelitsha, the third largest informal settlement in South Africa.
The exorbitant increase in prices is due to the lack of effective control mechanisms that no longer exist and subsidies don't exist to keep them low. It is also a reflection of insufficient competition in the market.
Only six products (for five different drugs for DR-TB) have been prequalified by the World Health Organization, and only four sources (for two different drugs) are recommended for purchase this year.
WHO responded to the growing need for drugs against drug resistant TB in 2000, creating the Green Light Committee, which reviews official health and non-governmental projects and the possibility they would allow access to medicines of proven quality at reduced prices.
Although the Committee is theoretically useful, the bureaucracy has prevented several treatment programs around the world from being of benefit.
In 2010, only 12,000 patients were enrolled in treatment programs approved by the Committee, against 440,000 new cases of the disease and 150,000 deaths, according to MSF. Only 13 percent of the estimated market of drugs for DR-TB is currently channeled through the Global Drug Facility of the WHO.
"WHO has responsibility for this disaster," Goemaere said.
Non-governmental organizations lobbied WHO for years until it created the Committee. But strict conditions and cumbersome administrative procedures prevent many health care providers from benefiting.
"The Committee provides few incentives because their quality guarantee endorsement is much more bureaucratic and centralized. The rules are self-limiting, making WHO into a doorman more than someone who provides support," Goemaere pointed out.
WHO's chief medical officer for TB in South Africa, Kalpesh Rahevar, recognized the Committee's administrative barriers, but said the agency had begun a reform process in early 2010.
"We're trying to simplify the request process," said Rahevar. "WHO also plans to extend its mandate to monitor TB programs worldwide, not just those that are involved with the Committee."
But until then, hundreds of organizations and health departments will have to keep on buying drugs to treat drug resistant TB from pharmaceutical companies that offer products of doubtful quality and high prices.
The Health Department of South Africa is one of them. Instead of requesting membership to the Committee, the ministry purchases drugs at fixed prices directly from South African subsidiaries of U.S. manufacturers, Sandoz Aventis and Sandoz.
According to the temporary Director of the department for treatment of tuberculosis, communications and social mobilization, Garvon Molefe, the ministry decided to buy medicines exclusively local, even if more expensive, in order to benefit the national economy.
"The reason why the Department doesn't continue the Committee's initiative is that after an alarming unemployment rate in South Africa, they do not want to waste the local pharmaceutical firms that give work to South Africans," he told IPS.
The Department currently spends $4,400 for treatment for each DR-TB patient. Goemaere said MSF, through the Committee, pays about 30 percent less for the same drugs, which means more patients can be treated for the same money.

Translated from the Spanish version by: Lisa Karpova
http://english.pravda.ru/health/06-07-2011/118403-Tuberculosis_disease_of_the_poor-0/

MALNUTRITION: Somalia: MSF Stepping Up Malnutrition Intervention As Horn of Africa Food Crisis Worsens

July 8, 2011


Somalia 2011 © MSF: Women and children seeking care in Dinsoor, Somalia.

Organization Hopes for Further Expansion in Al-Shabaab Territory
The announcement by Al Shabaab, one of the main armed factions in Somalia, that foreign relief organizations would be welcomed in territories under their control has raised hope that it will be possible to mount a desperately-needed scale-up of assistance inside the country, said the international medical and humanitarian organization Doctors Without Borders/Médecins Sans Frontières (MSF).
The announcement comes at a time of great urgency, when many lives hang in the balance. The eastern regions of the Horn of Africa have experienced consecutive poor rainy seasons, resulting in one of the driest years in decades in many pastoral zones. The impact has been exacerbated by high local cereal prices, high livestock mortality, ongoing conflict, and restricted humanitarian access in some areas. All this is happening against the backdrop of a 20-year civil war that has ravaged large parts of Somalia, displaced hundreds of thousands of people, and made it ever more difficult to reach the few places where food aid and health care is available.
“MSF has been working continuously in Somalia for over two decades running large-scale medical programs,” says Joe Belliveau, MSF operational manager. “We have managed to maintain our programs under Al Shabaab, but restrictions on supplies and international support staff have prevented us from scaling up further. We hope that the Al Shabaab statement leads to a lifting of these restrictions.”
MSF teams already present in various locations inside Somalia are extended nearly to their limits, while others are assisting exhausted refugees crossing Somalia’s borders into Ethiopia and Kenya.
“Most of our therapeutic feeding programs in Somalia are running over capacity, with more than 3,400 children currently enrolled in our nutritional programs,” adds Belliveau. “We are running emergency nutritional projects in several locations in the Lower Juba valley region, in Galgaduud, Mudug, Lower Shabelle, and Bay regions. [During] the past weeks we’ve seen a sharp rise in cases with some people traveling hundreds of kilometers to get access to health care and treatment for their malnourished children.”
For example: ‘Ader Mohammud, 19, travelled around 250 kilometers [150 miles] to bring her weakened 11-month-old daughter, Najmo, to MSF’s treatment center in Galcaayo. The long journey was almost too late and too long for the baby girl. “I could not afford the transport cost [approximately $8]," her mother says. "I have no support in Galcayo; I survive only with what other patients and caretakers give me.” Though her daughter is getting treatment at the moment, ‘Ader does not know how she will get home; she thinks she may have no choice but to sell the food rations she’ll get upon departure to pay for transport.
The situation is equally dire elsewhere in Somalia. “In the town of Marere [in southern Somalia] we noted a sharp increase in cases of severe malnourishment amongst people coming from all over the Juba valley,” says Belliveau. “The majority of the hospital beds in Marere are currently occupied by malnourished children in need of intensive care, and additional staff has been recruited to assist.”
Meanwhile, tens of thousands of Somalis have been fleeing to Kenya and Ethiopia in search of assistance. Waves of people continue to arrive every day at the sprawling Dadaab refugee camp in eastern Kenya. With the camps already badly overcrowded—originally built to hold 90,000 people, they now house four times that number—many are forced to seek shelter in the surrounding desert. In an assessment on the outskirts of one of Dadaab’s camp sites, MSF teams found extremely high malnutrition rates among new arrivals. There was a 37.7 percent rate of global acute malnutrition (GAM) and a 17.5 percent rate of severe acute malnutrition (SAM) among those surveyed. And 43.3 percent of children aged five to 10 were malnourished. As a consequence, MSF admitted 320 children in their Inpatient Therapeutic Feeding Center in June alone—three times as many as in the same month last year.
In addition, MSF is very concerned about delays in provision of assistance to the newly-arrived refugees. Since June 30, refugees received food for 15 days upon their arrival, but then told to wait as long as 40 days for the second food ration. “Families arriving in Dadaab are seeking a safe haven, and it is unacceptable that they should be made to wait this long to receive even the most basic form of assistance, food and water,” says Emilie Castaigner, the MSF’s Acting Head of Mission in Kenya.
In Dolo Ado, in southeastern Ethiopia’s Liben zone, in Somali Regional State, around 1,400 refugees cross the border every day—2,700 on June 28 alone. Dolo Ado already hosts almost 100,000 refugees in camps originally designed for 45,000 people. MSF screened children under 5 years old upon their arrival and found that 37 percent were malnourished. MSF is currently treating more than 6,800 children in these nutritional programs.
“MSF is increasing its capacity [in these camps] but the operational limits are being reached”, explained Alfonso Verdú, head of MSF operations in Ethiopia. "The engagement of other organizations to the nutritional crisis is essential while the present ones should uphold their responsibilities to avoid the deaths of many vulnerable people.”
MSF has worked continuously in Somalia since 1991 and currently provides free medical care in eight regions of southern Somalia. Over 1,300 Somali staff, supported by approximately 100 staff in Nairobi, provide free primary healthcare, malnutrition treatment, support to displaced people, surgery, water and relief supply distributions. MSF does not accept any government funding for its projects in Somalia, all its funding comes from private donors.
http://www.doctorswithoutborders.org/news/article.cfm?id=5427&cat=field-news

MALARIA (and more): Medical Innovations in Humanitarian Situations: The Work of Médecins Sans Frontières

Purchase book on Amazon.comhttp://www.amazon.com/Medical-Innovations-Humanitarian-Situations-Fronti%C3%A8res/dp/1461105951/ref=sr_1_1?ie=UTF8&s=books&qid=1307119783&sr=8-1

Download the book in PDF format (FREE) http://web1.doctorswithoutborders.org/publications/book/medicalinnovations/medinnovbk.pdf

Watch a video of the June 1 webcast now for an in-depth look at how innovations introduced over the past 40 years have improved MSF's medical humanitarian work. Innovations in the Field
http://www.doctorswithoutborders.org/publications/book/medicalinnovations/book.cfm?id=5204&cat=medical-innovations


MSF practices innovation in the field every day. See stories of innovation in our current projects:
Child Mortality Lower With Better Food
Revolutionary Advance in Malaria Treatment
Combating Chagas Disease

Medical Innovations in Humanitarian Situations explores how the particular style of humanitarian action practiced by Doctors Without Borders/Médecins Sans Frontières (MSF) has stayed in line with the standards in scientifically advanced countries while also leading to significant improvements in the medical care delivered to people in crisis.
Through a series of case studies, the authors reflect on how medical aid workers dealt with the incongruity of practicing conventional evidence-based medicine in contexts that require unconventional approaches.
http://www.doctorswithoutborders.org/publications/book/medicalinnovations/?id=5268&cat=medical-innovations

MALNUTRITION: The vital statistics of hunger

4 July 2011 (IRIN)

 Photo: Action contre la Faim
Aid workers and health officials measure a child's height and weight in western Chad

 Louise Masese-Mwirigi, an analyst recording nutrition data in southern Somalia with her team, have on occasion had to turn away from a village because the local authority that consented to the survey a week ago is no longer in charge or may have changed their minds when they arrive. Fighting between the government, its allies and various armed groups in parts of Somalia has severely restricted humanitarian space.
“The situation is uncertain in Somalia and access is a problem - especially in the last two years in central and southern Somalia,” said Masese-Mwirigi, who works for the UN Food and Agriculture Organization’s Food Security and Nutritional Analysis Unit (FSNAU) for Somalia.
Armed with an electronic weighing scale and a metre-long board to measure the height of children, Masese-Mwirigi and her team, led by Mohamed Moalim, along with Action Contre la Faim (ACF), a food relief NGO, have carried out a survey in the Mogadishu region, where the capital is located.
The survey is the first in seven years. “It took a month of planning… we could access six districts but had to let go of the remaining three because of security concerns.”
A rapid assessment by FSNAU in Mogadishu in December 2010 picked up high levels of malnutrition based on the measurement of the middle upper arm circumference (MUAC) - a quick, easy and cheap approximate measure of malnutrition in children younger than five years. "We felt we needed more information through a comprehensive nutrition survey, given the rains had performed poorly and the MUAC results were indicating high levels of malnutrition in the town."
The MUAC measurement uses a long strip of plastic with a series of colour-bands that is put around a child’s bare upper arm. The colours show the level of malnutrition: green indicates a 135mm circumference, which is normal; yellow - 125mm to 134mm - shows a risk of malnutrition; orange - 110mm-124mm means moderate malnutrition; red, for measurements less than 110mm, is an indication of severe malnutrition and risk of death.
In the past two years FSNAU have had to depend entirely on MUAC in parts of the conflict-hit areas. “It is less resource-intensive, and quick and ideal for emergency situations, but ideally we would like a more thorough survey,” Masese-Mwirigi said.

Detailed data
A thorough survey would take into account four variables - age, weight, height and gender - as well as the MUAC. Crude mortality rate (usually measured in deaths per 10,000 people per day in emergency situations), rate of disease prevalence, child care and feeding practices, household food security, and water and sanitation indicators, are also taken into account to understand the overall nutrition situation.
When two of the anthropometric variables are used together they are called an index. Three indices are commonly used to assess the nutritional status of children: weight for age (WFA), height for age (HFA) and weight for height (WFH).
These indices are then compared to a reference standard to get a sense of the severity and distribution of the nutritional problem in a country.
The survey is the first in seven years. It took a month of planning… we could access six districts but had to let go of the remaining three because of security concerns
The WFA of a child compared to a reference population will tell if the child is normal, overweight or underweight. HFA indicates whether the child’s height is normal for his or her age. If the child is not as tall as expected then he or she is stunted, reflecting a long-term, chronic problem - stunting is a good indicator of chronic malnutrition.
WFH is commonly used in acute emergencies to determine the scale of the crisis. It is often used when the child’s age is not known, and in countries like Somalia, where hardly any public records of births and deaths exist. WFH is regarded as a good indicator of acute or short-term exposure to a negative environment, such as a drought, as it reflects recent weight loss or gain. WFH is a measure of acute malnutrition.

Room for error
With so many measurements involved there is always a lot of room for error.
For instance a baby can often be not held properly to measure its length, or perhaps the child is not standing straight. Aid organisations are constantly trying to improve the skills of surveyors involved in taking measurements by organising training workshops periodically.
Determining the correct age can also be problematic. “We use the calendar of events to accurately determine a child’s age,” explained Masese-Mwirigi. Events like major natural disasters or elections can indicate when a child was born.
The other contentious issue in measuring malnutrition is what is considered average. The World Health Organization (WHO) provides a reference of growth standards, against which surveys calculate their deviations from the norm.
Yet the WHO growth standards might not be the norm for a particular ethnic population that is naturally long-limbed, like Kenya’s Maasai, or short-limbed, like the Gurkhas of Nepal. Even though the WHO standards were recently updated to better reflect human genetic diversity some experts feel country- or region-specific growth standards should be developed.
Prominent experts like Mark Myatt, Senior Research Fellow at the Division of Epidemiology, of the Institute of Ophthalmology, University College, London, feel MUAC is a much more accurate measure.
But that is not all. There are different scales of malnutrition. For individuals malnutrition can be moderate acute or severe acute.
To work out levels of malnutrition, WFA, HFA and WFH measurements are used to calculate and classify using what is known as the “percentage of the median” and “Z-scores”.
For instance, in expressing the WFH as a “percentage of the median”, a child’s weight is divided by the average weight for a child of that height, as provided in the WHO growth standards, and then multiplied by 100 percent. Fortunately, there is computer software that does the calculation.
The “Z-score” represents the difference between the observed weight and the median weight of the reference population, expressed in standard deviation units. When the percentage of the median is less than 70 percent, and the Z-score is less than -3, or oedema is present, the child is said to be suffering from severe acute malnutrition.

GAM or SAM?
Populations are described as severe acute or global acute. “Global acute malnutrition (GAM) refers to the total cases of moderate acute and severe acute malnutrition (SAM) in a population,” Médecins Sans Frontières (MSF), the medical NGO, notes in their useful manual, A Beginner’s Guide to Malnutrition.
GAM is calculated with the Z-score defined as a weight-for-height index less than -2 standard deviations from the mean weight of a reference population of children of the same height.
A GAM value of more than 10 percent generally identifies an emergency. Commonly used thresholds for GAM are less than five percent (acceptable), between five and just under 10 percent (poor), between 10 percent and under 15 percent (serious), while anything more is critical.
Clinical signs such as bilateral oedema - swelling in the feet, legs or face caused by an extreme shortage of protein - are a separate indicator of severe malnutrition in children.
“We recorded a GAM rate of 15.2 percent for Mogadishu in our survey,” said Masese-Mwirigi. In Somalia the FSNAU has been recording GAM rates of 15 percent and above for a long time, GAM rates of over 15- 20 percent indicate a critical nutrition situation, while rates over 20 percent are seen as very critical. The GAM rates reported in Mogadishu town are high, also given that there are a large number of feeding interventions in the town.
Prices of the staple grains - maize and sorghum - have gone up by between 52 and 95 percent in most markets. FSNAU reports that in some areas prices have doubled and even tripled since 2010.
In 2011 the major rainy season began late and was poorly distributed across time and place in southern Somalia - the second bad season consecutively, as the first harvests in January failed.
A smaller cereals harvest, low stocks and poor access because of continued conflict to Bakara, the main market in Mogadishu, have made basic foodstuffs harder to get and more expensive.

http://www.irinnews.org/report.aspx?reportid=93128

MALNUTRITION: Somalia: MSF is Denied Access to Drought-Affected Areas

8 June 2011
After weeks of negotiation, Médecins Sans Frontières (MSF) says it has been blocked last April by the local authorities from conducting emergency medical activities in Buurhakaba district in the Bay region of South Central Somalia, where drought affected population needed nutritional support and clean water.
MSF's planned emergency response included water trucking, nutrition screening for children under the age of five, and food distribution for malnourished children. However, the authorities have not allowed MSF to access the area.
Buurhakaba district is highly populated, with estimated 125 000 people. At the moment, there is no other actor providing nutrition support to this population.
MSF is an independent medical organization with projects in eight regions of Somalia. Over 1,500 Somali staff, supported by approximately 100 staff in Nairobi, provide primary health care, malnutrition treatment, health care and support to displaced people, surgery, and water and relief supply distributions in some locations.
MSF offers assistance to people based only on need, irrespective of race, religion, gender, political or clan affiliation.
MSF does not accept any government funding for its projects in Somalia, all its funding comes from private donors.
http://allafrica.com/stories/201106081186.html

MALNUTRITION: Niger: Child mortality observed to be 50% lower with better food

24 May 2011


MSF Niger study reinforces that high-quality nutritious foods should be a pillar in Global Fight Against Childhood Mortality; G8 countries should ensure that appropriate foods reach vulnerable children

Mortality rates were observed to be 50 percent lower among a large group of young children in the west African nation of Niger in 2010, after they received a highly nutritious supplemental food, according to preliminary findings in a study by the international medical humanitarian organization Médecins Sans Frontières (MSF).
The encouraging findings reinforce the need for international donors and policymakers to make high-quality foods a cornerstone of childhood health programs, especially in areas where malnutrition is rife.
Malnutrition weakens the immune system, exposing a child to higher risk of death from other illnesses, such as malaria, respiratory infections, and diarrhea. Adding a quality supplemental food to an essential package of care, including includes vaccination and effective treatment and prevention of primary ‘killer diseases’ of young children, will accelerate the fight against child mortality.
Last year in Muskoka, Canada, G8 member states committed to refocus efforts over the next five years to cut mortality rates of children under five years of age, by two-thirds from 1990 levels. At their meeting this week in Deauville, France, G8 members should commit to ensure that appropriate foods reach vulnerable children, MSF said.
“Our preventive strategies focused on getting a nutritionally appropriate food to children during the most crucial time-the critical window of six months to two years of age-instead of waiting for them to start losing weight, and we observed child mortality rates to be lower by half,” said Dr. Isabelle Defourny, MSF program manager for Niger. “If donors and policymakers are serious about reducing child mortality rates, then providing child-appropriate foods must be made a standard component of any pediatric program in the world’s ‘malnutrition hotspots’.”
At any given time, an estimated 195 million children are affected by malnutrition worldwide. It contributes to at least one-third of the eight million annual deaths of children less than five years of age.
For several years, MSF has been developing preventive approaches to malnutrition-based on quality supplementary foods-in order to lower the burden of deaths in ‘malnutrition hotspots’ such as in the Sahel region of Africa. The Sahel features child mortality rates among the highest in the world. During a severe food and nutrition crisis in 2010 in the Sahelian country of Niger, local authorities, together with MSF and the Nigerien organization FORSANI (Forum Santé Niger), implemented the largest-ever distribution of supplemental foods designed to prevent malnutrition in young children.
Between July and December, 2010, three-to-six-month supplies of a ready-to-use paste rich in milk, minerals, and vitamins were distributed to approximately 150,000 children-most between six months and two years-of-age - in five districts of the Tahoua, Maradi, and Zinder regions. Some of the children also benefitted from protection rations (mainly cereals and fortified flours) provided by WFP. Pediatric healthcare for common childhood illnesses, such as malaria, and acute malnutrition, was also available in the distribution areas, including for the children who did not receive a nutritional supplement.
Epicentre, MSF’s epidemiology branch, conducted monthly surveys among a cohort of several thousand young children living in the distribution zones. All benefitted from monitoring for signs of malnutrition and illness. Children requiring medical care were referred to MSF and its partners working within Nigerien health-care facilities.
The mortality rate was seen to be more than 50 percent lower among those who received the foods tailored specifically to the nutritional requirements of young, growing children.
In the Madarounfa district in Maradi region, the observed mortality rate among children who received the enriched foods was 2.2 deaths per 10,000 children per day, compared to 5.3 deaths per 10,000 children per day among those who did not receive supplements. In the Guidan Roumji district of Maradi, mortality rates were 1.1 per 10,000 per day compared to 2.5 per 10,000 per day. In the town of Mirriah in Zinder region, the rates were 1.2 per 10,000 per day versus 3.2 per 10,000 per day.
“Providing young children with high quality nutritious foods has long been one of the foundational principles of successful malnutrition and child mortality reduction programs in Europe, Latin America and the United States, along with immunization, for instance,” said Dr. Susan Shepherd, MSF child nutrition advisor. “It’s time to stop applying different standards for children living in malnutrition hotspots. We can save children’s lives today if the appropriate resources are put behind similar interventions we deployed last year in Niger.”
Countries such as Mexico, Thailand, the United States, and many European nations, have successfully reduced early childhood malnutrition and mortality through programs that ensure infants and young children from even the poorest families have access to nutritious foods, such as milk and eggs. However, many food-insecure families cannot afford these animal-sourced foods, which contain the high-quality proteins, fats, and other essential nutrients that children require. National programs that fill this nutritional gap for young children are essential.
The development in recent years of a new generation of nutritional foods tailored to the needs of the most vulnerable children, which are simple to use, make possible the establishment of a new standard in childhood mortality prevention.

In 2010, in addition to malnutrition prevention activities, MSF and its partners, FORSANI and BEFEN / ALIMA, carried out pediatric and nutritional activities in 64 primary care facilities and nine hospitals in Niger’s Tahoua, Maradi and Zinder regions. Approximately 150,000 children suffering from malnutrition were treated-nearly half of all the malnourished children treated in the country in 2010-of whom approximately 24,000 were hospitalized. Between 85 and 92 percent of children were discharged. MSF and its partners also treated 216,330 cases of malaria among children less than five years of age, conducted more than 370,000 pediatric consultations, and admitted more than 13,000 children to hospital.

http://www.msf.org/msf/articles/2011/05/child-mortality-observed-to-be-50-lower-with-better-food.cfm

MALNUTRITION: Getting the recipe right for US food aid

JOHANNESBURG, 13 May 2011 (IRIN)

 Photo: Manoocher Deghati/IRIN
More of all the good things - protein and vitamins

Changing the food the US government supplies as aid could deliver better results and still save money, a new study says. The review for the US Agency for International Development (USAID) by researchers at the Tufts University Friedman School of Nutrition Science and Policy has been welcomed by NGOs and US food aid experts, but the findings have also come in for some criticism.
The two-year review considered if USAID food aid was up to date with current science, especially in its use of blended food and whether programmes matched the right products with expected outcomes.
"What we're recommending is approaches to enhance the many great things already being done with US food aid under the most difficult circumstances imaginable," Amelia Reese Masterson, research coordinator of the review, wrote to IRIN, referring in part to USAID’s budget pressures.
The review came up with 20 recommendations on some of the food products and programmes under Title II of the US Food for Peace Act, which covers food aid provided in emergency and non-emergency situations.

Getting the ingredients right
The Tufts review addressed the issue of the source of protein in food products for children, pregnant and lactating women, and undernourished people on HIV medication.
Médecins Sans Frontières (MSF) has noted that US food aid destined for children usually comprises fortified flours based on grains and pulses such as corn-soya blend (CSB) or wheat-soy blend (WSB) and has lobbied for the inclusion of other sources of protein, vitamins and minerals.
Recent scientific evidence shows that animal-source proteins such as milk, better promote the growth of muscle tissue and resistance to infections, and are critical to children recovering from severe malnutrition, the Tufts review agreed. It also acknowledged that ready-to-use therapeutic foods (RUTF), usually lipid-based spreads, whose ingredients typically include nuts and milk powder, have led to a radical change in the way severe malnutrition is treated.
The review recommended that a wider range of products, offering varying quantities and types of nutrients for different programmatic contexts, be made available.
It is here that the review has contradicted itself, Nathalie Ernoult, Stephane Doyon and Susan Shepherd, members of the MSF's nutrition team, maintained in a written submission to the Tufts academics.
"The report itself states that there can be no 'one-size-fits-all' food supplement, and we could not agree more," the MSF team said, yet it "focuses primarily on how to improve the nutritional value of fortified blended flours."
The Tufts study argued for a single formulation for a cost-effective, enhanced CSB, which they dubbed CSB14, to meet the minimum nutritional requirements of three key target groups: infants from 6 to 11 months; children between one and three years; and pregnant women.
The MSF team said at least two enhanced CSB formulations would be necessary: one tailored to the needs of infants and young children and those affected by moderate acute malnutrition; the other for older children and adults.
UN organizations the World Food Programme (WFP) and the UN Children's Fund (UNICEF) are also considering experimenting with different formulations of CSB.
"As a field-level agency and occasional implementing partner for UNICEF and WFP, we [MSF] cannot over-emphasize the need for coherence in the nutritional supplements on offer for a given category of beneficiary," the MSF team said. "If the fortified foods provided by WFP, UNICEF and USAID for similar programmes are not interchangeable, nutrition programmes will simply become confused and ineffective."
MSF maintained that the formulation for younger children should have a higher protein content from animal-sourced food; and that the proposed fortification levels of iron and zinc were also too low.
Zita Weise Prinzo of the World Health Organization (WHO) said they were recommending that the diets of moderately malnourished children contain animal-sourced foods, without specifying how much. WHO is expected to release its guidelines for food formulations for moderately malnourished children in June 2011.
According to MSF, the proposed second formulation for older children and adults, would not require animal-sourced ingredients, and the current CSB recipe, with some adjustments to its vitamin and mineral content, would serve the purpose.
However, a senior nutritionist who preferred not be named told IRIN that in many instances it would be hard to imagine relief agencies successfully distributing two or more similar looking products for different segments even within a single family.
"Most large-scale programmes using CSB-type products involve take-home rations. It would be difficult for a programme to ensure the proper use of several similar products at home. The solution could be to have one ‘generic’ option used by most big programmes, similar to that proposed by the [Tufts] paper, and then several other options that would be used by ‘speciality’ programmes."
The CSB14 formulation depends on the addition of oil fortified with vitamin A to provide enough of the vitamin. "Our experience shows that it is difficult to count on the prescribed amounts of oil being added to the porridge in the home, not to mention all the logistical difficulties encountered with the distribution of multiple commodities to constitute a single ration," the MSF team pointed out.
The chemical forms of micronutrient supplements proposed by Tufts also differed from those on the list approved by the WFP, the biggest dispenser of US aid. "It is very important to come to common agreement on a list of acceptable chemical forms for all additives," the MSF team noted.

PEPFAR food
Programming should "be evidence-based, not driven by simple data on tonnages and 'hungry people fed', but by an understanding of the unit cost of impact," and this included HIV/AIDS-related programmes, said the review. It found that orphans and vulnerable children, and HIV-positive pregnant and lactating women, identified for priority food assistance in the US President's Emergency Plan for AIDS Relief (PEPFAR), were receiving not getting priority compared to other HIV-positive women and adults.

Photo: Jason McLure/IRIN
US food aid is evolving

The review suggested stronger links between ongoing antenatal, Prevention of Mother-to-Child Transmission (PMTCT), and Maternal and Child Health (MCH) services, and with programmes treating malnourished children.
PEPFAR country coordinators reported that requests to approve the use of funds for food were "commonly met with caution", the review said, which "contributes to low coverage of food assistance within programmes", and PEPFAR needed to send a stronger signal on supporting the allocation of funds to food in HIV support.

Saving money
Budget-constrained donors were "facing hard trade-offs between feeding as many people as possible and providing higher quality foods to improve nutritional impact per person," said Christopher Barrett, a food aid expert who teaches development economics at Cornell University in the US.
Scarce resources should be put to work more efficiently, and the Tufts review contributed significantly to improving understanding of these tradeoffs by policymakers, operational agencies and commercial suppliers, Barrett commented.
"It's important to move beyond a dollar-per-ton of food metric - the conventional way of looking at things - since that does not take into account exactly what kinds of foods are used for what purposes," said Patrick Webb, principal investigator of the Tufts review project.
"If we become more efficient in treating or preventing malnutrition, then it's the cost per case of malnutrition treated or prevented that matters, and that will go down when the appropriate tools (foods)are used in the right ways, even if unit costs of products rise slightly... because less is needed (over a shorter period of treatment)."
Some of the Tufts recommendations would cost more money - the addition of dairy products, new smaller packaging of some products for mothers and infants to prevent it from being consumed by the entire family - but Webb said the costs would be offset by improved targeting of the enhanced products.
Barrett noted that "With greater bang for the buck, it also becomes easier to defend valuable food aid programmes against those looking to trim budgets."
The review, the issues it covers and its recommendations will be debated at the US government's annual conference on food aid in June.
http://www.irinnews.org/Report.aspx?ReportID=92717

MALARIA: Sierra Leone: Low referral completion of rapid diagnostic test-negative patients in community-based treatment of malaria in .

Thomson A, Khogali M, de Smet M, Reid T, Mukhtar A, Peterson S, von Schreeb J. Malar J. 2011 Apr 17;10(1):94. [Epub ahead of print]


BACKGROUND:
Malaria is hyper-endemic and a major public health problem in Sierra Leone. To provide malaria treatment closer to the community, Medecins Sans Frontieres (MSF) launched a community-based project where Community Malaria Volunteers (CMVs) tested and treated febrile children and pregnant women for malaria using rapid diagnostic tests (RDTs). RDT-negative patients and severely ill patients were referred to health facilities. This study sought to determine the referral rate and compliance of patients referred by the CMVs.

METHODS:
In MSF's operational area in Bo and Pujehun districts, Sierra Leone, a retrospective analysis of referral records was carried out for a period of three months. All referral records from CMVs and referral health structures were reviewed, compared and matched for personal data. The eligible study population included febrile children between three and 59 months and pregnant women in their second or third trimester with fever who were noted as having received a referral advice in the CMV recording form.

RESULTS:
The study results showed a total referral rate of almost 15%. During the study period 36 out of 2,459 (1.5%) referred patients completed their referral. There was a significant difference in referral compliance between patients with fever but a negative RDT and patients with signs of severe malaria. Less than 1% (21/2,442) of the RDT-negative patients with fever completed their referral compared to 88.2% (15/17) of the patients with severe malaria (RR=0.010 95% CI 0.006 - 0.015).

Conclusions
In this community-based malaria programme, RTD-negative patients with fever were referred to a health structure for further diagnosis and care with a disappointingly low rate of referral completion. This raises concerns whether use of CMVs, with referral as backup in RDT-negative cases, provides adequate care for febrile children and pregnant women. To improve the referral completion in MSF's community-based malaria programme in Sierra Leone, and in similar community-based programmes, a suitable strategy needs to be defined.

PMID: 21496333 [PubMed - as supplied by publisher]
http://www.ncbi.nlm.nih.gov/pubmed/21496333

POVERTY: Stillbirths could be halved

DAKAR, 27 April 2011 (IRIN)

 Photo: MSF
A midwife listens to the foetal heartbeat of an expectant mother in Afghanistan (file photo)

 Preventing stillbirths can cost just US$2.32 per mother if governments, the private sector and international institutions adopt a package of 10 health interventions, rather than allowing stillbirths to be an almost invisible problem.
If ten recommended interventions were 99 percent implemented in 68 priority [low and middle-income] countries, the number of stillbirths could be halved, said Professor Zulfiqar Ahmed Bhutta of the Aga Khan University Medical Centre in Karachi, Pakistan, author of one of a series of papers on stillbirth published in The Lancet medical journal papers.
Even if the interventions were 60% covered, stillbirths could be reduced by one-quarter. Some 2.64 million foetuses die after the 28th week of pregnancy, mostly in low- and middle-income countries.
Interventions include: basic and comprehensive emergency obstetric care; skilled care at birth; detection and management of foetal growth restriction; detection and management of hypertension in pregnancy; elective induction in post-term pregnancies; insecticide-treated bed nets and intermittent prophylaxis to prevent malaria; detection and treatment of syphilis; folic acid supplementation; and management of diabetes in pregnancy.

Identifying solutions
Stillbirths have largely been neglected in policy prioritizing for a variety of reasons. “There was little in terms of verified data for stillbirths and even less for its categories - whether intrapartum [during childbirth] or antepartum [before childbirth] - and risk factors, and little confidence that interventions could make a difference,” said Bhutta.
The Lancet series hopes to change this perception by re-framing stillbirths so that they are not seen as an unexplained event that occurs in the womb, but as something that is potentially preventable if appropriate care is given during pregnancy and birth.
Bhutta suggested in his paper that cheaper solutions, such as improving antenatal care, preventing malaria, detecting and treating syphilis, be adopted immediately, while more expensive interventions, such as training health workers, and procuring equipment for emergency births, could be built up gradually.
Other interventions would require improved long-term funding allocations, including addressing hypertension, diabetes, post-term pregnancy (which lasts longer than usual) and monitoring foetal growth problems.
Providing skilled attendants at birth would reduce intrapartum stillbirths by about 23 percent, said Dr Joy Lawn, of NGO Save the Children, making it the most effective single intervention. Almost half the women in low- and middle-income countries give birth at home, without any skilled assistance.
Voucher schemes or conditional cash transfers could be used to encourage women to have their babies in a facility, since in settings where the highest infant mortality occurs, only half of all births take place in facilities.

Maternal mortality
In high-income countries, where most women receive fairly good quality care while giving birth, the proportion of stillbirths is less than 10 percent of all births.
Sub-Saharan Africa, which has a scarcity of skilled birth attendants, has been making swifter progress than Asia in encouraging women to give birth in a facility. “One year ago, the international community became acutely nervous about the lack of progress on reducing maternal mortality,” Lawn said.
A year later, maternal mortality in sub-Saharan Africa had fallen by 2.6 percent. “This marks significant progress… For stillbirths, a lot of the focus in high-income countries has been because parents have called for it. Setting a global policy goal is one good way of getting it on the agenda.”
One-third of African countries could meet the Millennium Development Goal to reduce childhood mortality (Goal Four) and to improve maternal health (Goal Five), which would also reduce stillbirths.
Some investments in reducing maternal mortality are already having a positive effect on the number of stillbirths, but these results are not given due significance. “Governments could argue for more investment if they counted stillbirths in the work they’re already doing,” Lawn told IRIN.
Saving mothers’ lives costs $23,000 per death averted, but if stillbirths and neonatal deaths are included, the figure drops to $2,700 per life saved. “Our single message is, ‘Care at birth may be more expensive, but it gives you the biggest bang for your same buck if you count it properly’
http://www.irinnews.org/report.aspx?reportid=92590

POVERTY: SUDAN: North Darfur water project helps protect women from sexual violence

NAIROBI, 27 April 2011 (IRIN)

 Photo: UN Photo/Albert Gonzalez Farran
A woman in El Fasher, North Darfur, using a Hippo Water Roller

A water project supported by the UN-African Union peacekeeping force (UNAMID) in eight villages of North Darfur will not only facilitate residents' access to water but also help to reduce sexual and gender-based violence (SGBV) in the region, local residents and UNAMID officials said.
“For years we have been afraid of being attacked while fetching water and collecting firewood; it is not always possible to move in groups and we are often escorted by men or UNAMID peacekeepers,” a resident of Kuma Garadayat village, who declined to be named, told IRIN on 27 April.
Kuma Garadayat, 60km from El Fasher in North Darfur, is one of the villages where the water project was launched on 26 April. The eight villages host at least 3,000 returnees.
About 30,000 rolling water containers, with a capacity of 75l each, the equivalent of four jerry cans, were distributed to women in the villages, all with poor access to water and severely affected by drought during the dry season. “I hope through the water carriers, things will become easier for us; we’ll be less exposed,” the villager added.
According to Médecins Sans Frontières (MSF), most SGBV cases in Darfur still occur during water and firewood collection.
Because of generally poor access to justice, a sense of impunity, and the social stigmas attached to SBGV, the international community in Darfur has launched several prevention, protection and response activities, including firewood patrols.
The water project is part of broader UNAMID-backed recovery projects, which include training midwives and helping to improve health and education in villages. Several thousand water hippos will be dispatched over the next two weeks, mainly to women heads of households, the vulnerable and people living far from water points, says UNAMID.
The barrel-shaped water carriers are designed to reduce the physical burden of carrying water and would benefit women and children who are mostly in charge of water collection in Sudan.
“One of the major sources of conflict in Darfur is access to water,” said Ibrahim Gambari, the Joint Special Representative and head of UNAMID, in a statement.
“This project is to make life easier and safer for women, and also to underscore the fact that water hasn’t only been a source of conflict, it is also the solution,” he said. “It is our hope that their [the barrels’] use will not only support former displaced persons but also help protect civilians as they return to resume their lives.”
http://www.irinnews.org/report.aspx?reportID=92597

MALARIA: New malaria drug better but not cheaper

JOHANNESBURG, 21 April 2011 (IRIN)

 Photo: Ashley Clements/Flickr
Quinine takes four hours to be administered through an IV drip

The World Health Organization (WHO) this week recommended a change in the first-line treatment for malaria that could save nearly 200,000 lives a year, but health activists in Africa are bracing themselves for a potentially long battle in getting the new guidelines implemented.
Most cases of malaria are uncomplicated and non-fatal, particularly when patients have been exposed to the parasite and developed an immune response to it, but about eight million cases a year progress to “severe” malaria, which resulted in 781,000 deaths in 2009. Ninety percent of those occurred in Africa, where the disease is the leading cause of death in children.
Quinine has been the drug of choice for treating severe malaria for years, but it is difficult to administer and can have dangerous side effects.
"It requires a lot of calculation," said Veronique De Clerk, medical coordinator for international NGO, Médecins Sans Frontières in the northern Ugandan district of Kaabong. "You need to dilute it into infusions, and those infusions need to run through an IV [intravenous line] for four hours [every eight hours], and you need to monitor that, so it requires well-qualified personnel."
In rural Africa, where health workers are in short supply, it was common for patients to receive too much or too little quinine, with results that could be deadly, said De Clerk. "Recently, some studies from Uganda showed one in four administrations of quinine weren't correct."
WHO has recommended artesunate for severe malaria in adults since 2006, but this week revised its guidelines to include children, based on findings from a nine-country trial in Africa in 2010, which found that for every 41 children treated with artesunate instead of quinine, one life could be saved.
"It's very rare you have such a clear benefit of one drug over another, especially in neglected diseases like malaria," commented Nathan Ford, medical coordinator for MSF's Campaign for Access to Essential Medicines.
Several large clinical trials in the last decade have demonstrated that artesunate is safer, easier to use and more effective than quinine. It can be administered over three days either intravenously or through a daily intramuscular injection, meaning that non-medical personnel could be trained to provide the drug, bringing life-saving treatment closer to remote, rural communities.
It's very rare you have such a clear benefit of one drug over another, especially in neglected diseases like malaria
This week, MSF released a report, Making the Switch, which lists the benefits of treatment with artesunate rather than quinine, and the challenges in translating this evidence into policy and practice.
The biggest barrier is that artesunate costs two or three times more than quinine - around US$3.30 to treat one child compared to $1.3 for quinine - with additional costs for training health workers to administer it.
"Any change in protocol which results in an increase in cost is going to be a challenge in countries where health budgets are over-stretched," Ford told IRIN. MSF put the additional annual cost of treating severe malaria globally with artesunate at $31 million.
Ford said international donors could absorb this amount fairly easily, but had not traditionally supported the cost of treating severe malaria and would be unlikely to offer support until governments took the lead by changing their national guidelines.
"The WHO guidelines are just the first step," he told IRIN. "[They] need to be translated into national and local guidelines and protocols, with adequate training."
WHO recommended abandoning the use of chloroqine as the standard treatment for malaria a decade ago, but health professionals in some African countries still prescribe it. "It's a matter of changing long-term habits and practices," Ford commented.
De Clerk noted that although Uganda's national guidelines listed artesunate as an alternative to quinine, in reality the drug was unavailable. "For government, the price is important, and quinine has a very long shelf-life, so they'd want to get rid of those stocks first," she said.
WHO has prequalified only one manufacturer to produce artesunate, but MSF hoped that rising demand would encourage more manufacturers to enter the market, improving supply and reducing the price, and making long-term donor support unnecessary.
In the meantime, said Ford, "what we want is a very clear message from donors to say that any country switching [to artesunate] will be supported by us to cover the increased costs in the short term."
http://www.irinnews.org/report.aspx?reportID=92551

MALARIA: Using Artesunate Instead Of Quinine

Geneva, April 19, 2011 – New MSF report calls on African governments, WHO and donors to urgently make the switch
Revolutionary Advance in Severe Malaria Treatment: Using Artesunate Instead Of Quinine Could Save 200,000 Lives Annually

After the revision of World Health Organization (WHO) guidelines yesterday, international medical humanitarian organization Médecins Sans Frontières/Doctors Without Borders (MSF) calls for a drug proven to reduce deaths in children suffering from severe malaria to be immediately rolled out in African countries. In its new report Making the Switch.MSF calls on African governments to follow new World Health Organization (WHO) guidelines, and switch from the far less effective quinine to artesunate treatment, which could avert nearly 200,000 deaths each year. MSF also calls on WHO and donors to support governments so this urgent treatment change can happen quickly.
“When children arrive at the clinic with severe malaria, they often are having convulsions, vomiting or at risk of going into shock, and you just want to be able to give them effective treatment quickly,” said Veronique De Clerck, Medical Coordinator for MSF in Uganda. “For decades, quinine has been used in severe malaria, but it can be both difficult to use and dangerous, so it’s time to bid it farewell. With artesunate, we now have a drug that saves more lives from severe malaria, and is safer, easier and more effective than quinine.”
Quinine has to be given three times a day in a slow intravenous drip that takes four hours, a treatment that is burdensome for both patients and health staff. Artesunate, in contrast, can be given in just four minutes, by giving a patient an intravenous or intramuscular injection.
A landmark clinical trial in late 2010 concluded that the use of artesunate to treat children with severe malaria reduces the risk of death by nearly a quarter. The study, carried out in nine African countries, found that for every 41 children given artesunate over quinine, one extra life was saved. Because of the complexities of administering quinine, children in the trial who were assigned to receive quinine were almost four times more likely to die before even receiving treatment.
MSF participated in the trial through its research affiliate Epicentre, with a research site in Uganda. MSF has since changed its own treatment protocols and now plans to work with national health authorities to roll out artesunate in its projects over the coming months.
The evidence is overwhelming, but MSF’s report stresses that change will not happen on its own. While WHO has now issued new guidelines recommending artesunate for treating severe malaria in children in Africa, it needs to also develop a plan to help countries make this switch. African governments must urgently change their treatment protocols and donors must send a clear signal to countries that they will support the additional cost where needed. Artesunate is three times more expensive, but the difference in cost of US$31 million each year for a global switch is very little for the nearly 200,000 lives that researchers say could be saved.
“We’ve been here before – when WHO changed its treatment recommendations for simple malaria in 2001 it took years for countries to actually make the switch, and shockingly, in some countries the far inferior drugs are still being used ten years on,” said Dr. Martin De Smet, who coordinates MSF’s malaria work. “With severe malaria, WHO needs to make sure that the change is much less sluggish, so lives can be saved immediately. There’s simply no excuse not to make the switch now.”
MSF provided malaria treatment to around one million people in 2010. Severe malaria kills over 600,000 African children under the age of five annually. Each year, around eight million simple malaria cases progress to severe malaria, where patients show clinical signs of organ damage, which may involve the brain, lungs, kidneys or blood vessels. ‘Making the Switch’, MSF’s new report calling for a change in protocol for the treatment of severe malaria in children can be downloaded from www.msfaccess.org