RAIN, RAIN, WHERE ARE YOU?

When I arrived in Boguila, I expected the rainy season…However, we have only had four or five days of rain since April. This is not enough, unquestionably not enough…

The population is hungry. The lack of rain is delaying the crop. Seeds cannot be planted because nothing grows without water. There are no (or very little) fresh vegetables. The national situation and the lack of security on the roads prevent the distribution of fresh produce from the capital to the regions. The markets have very little to offer – we can sometimes see a few tomatoes, cucumbers, onions. Otherwise, nothing. And the population grows hungry…

In our « fortunate » subconscious, we are assuming that everyone in Africa is hungry. What a stereotype! Also, don’t we tell our kids in Canada: « Think about the little children in Africa…They would eat what you have in your plate! » It’s true; the situation is quite problematic in many countries of this continent. However, here again, we are somewhat immunised to their suffering as we are not living in their conditions. Wouldn’t you be hungry if you did not have any food available or if you had to walk kilometers to find a little bit of beans? What would you do if the village market did not have any food items to sell? Would you be able to live with only one meal per day? To whom, in your family, would you choose to give the little food you have found – The kids because they have to survive? The dad because he has to find work in order to bring back a little food? The mom so that she can take care of the household and the kids? Difficult choices indeed…

According to UNICEF, four basic causes impact malnutrition and mortality – resources (human, structural, financial), political ideology, infrastructures and local priorities (MSF Nutrition Guidelines [edited version], 2006). As you know, the political and military situation in Central African Republic has been pointing toward chaos for a while. The Boguila population reports instances of looting, theft, and violence. In fact, some people do not go to work in the fields because they are afraid of the presence of this violence. This little country has been living with this uncertainty for a long time and this ambiguity can be felt all the way to small towns and villages just like Boguila. There is no financial support, no security, and the human resources and infrastructures are almost non-existent.



Twins Issan and Neya before their departure from the nutrition centre



We now have all the basic causes in place …and they bring without doubt the underlying causes of malnutrition with them. The lack of infrastructures and resources translate locally into (1) household food insecurity in regards to access to food and its availability; (2) changes in social care and the environment – direct caring of children and elderly, social and familial organisation; and (3) disruption in access to health care and water.



So at this instant, with all these causes present, the wheel of malnutrition starts to roll: the lack of food and the diminution in its quality increases the sensitivity to infections of individuals at risk (kids, elderly) because they are suffering from an impaired immune system. Illnesses start to appear and the lack of nutrients, their mal-absorption by the body and the decrease in food intake continues to decrease the immunity required to get better so their risk of infections increases and their length of stay in hospital augments, which reduces the immunity, which gets worse because there is no food, which…And so the child or the elderly finds themselves in a state of malnutrition, which can eventually lead to death.



In order to return to a healthier, a patient suffering from malnutrition must be admitted to the hospital and his treatment followed very closely. Most of our malnutrition cases are children. They arrive at our outpatient clinic in a precarious health, sometimes even too late. If you think about the images often shown on television of hungry African children, the following must inevitably come to mind: a thin child with a large abdomen or another with edematous eyes and legs. The first example suffers from « Marasmus » and the second, « Kwashiorkor ». These are the two clinical presentations of severe malnutrition with children; we can see them separately or combined together. In the three situations, metabolic function is seriously disturbed – the immune system is impaired, blood sugar is low, temperature decreases, electrolytes are in a state of imbalance, severe infections develop, apathy and lethargy are seen. These changes in the body can be translated by severe loss of muscle and fat mass in both presentations. In addition, with the Kwashiorkor, we see bilateral pitting edema in lower legs, feet, and face to which we can add skin lesions. All these can mistakenly hide the loss of muscle and fat mass.



Baby Moussa before he left Boguila



Hospitalization in the nutrition centre takes place over two phases, separated by a transition phase. The height and weight of the child are taken and a ratio (Z score) is calculated to determine the extent of the malnutrition. Phase 1 lasts usually seven (7) days. The goal of this stage is to restore and stabilise the body’s metabolic function. The child normally receives eight (8) meals per day; each meal is calculated according to the age, the weight and the height of the child, and consists of a measured portion of therapeutic milk F75. This special milk is meticulously formulated for the severe malnutrition cases and contains a limited amount of proteins, fat and sodium as well as a great caloric value (75kcal/100mls). This makes it much easier to digest and thus, favours the return of a normal metabolic function.



When the child shows a gain in energy and appetite, he/she is ready for the transition phase, which lasts between 1 and 3 days. At that time, the child continues to receive eight (8) meals per day but a progression from therapeutic milk F75 to F100 (similarly formulated but with more calories - 100kcal/100mls – and proteins) or Ready-to-use Therapeutic Food (RUTF) – nutritive bars or Plumpy’Nut® (peanut paste with milk). The bars are made with a mix of skim milk powder, cereal flour, fat, sugar, and vitamins and minerals. Each bar contains between 150-300kcal. Plumpy’Nut® essentially contains the same elements but its consistency makes it easier to take for younger children – it looks like peanut butter. In both cases, there is no cooking involved – they are ready for consumption!

At the end of the transition phase, the child moves to phase 2. The number of meals changes from eight (8) to six (6) per day. At this time, we are looking for a substantial weight gain so that treatment can come to an end. This phase also prepares the child to

start eating traditional food as well – when discharge approaches, we encourage moms and dads to offer home meals and complement with Plumpy’Nut® or the bars. As soon as the targeted weight is reached, the child and his/her family can go home. It is at that time that we can see the success of our nutrition program. The smile of these children is priceless! Following discharge, the child continues to be followed by the outpatient nutrition clinic once a week to ensure continued weight gain and health stability.



Once again, thank you for reading me. And please, send us a little rain…

Janique