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Skip to 0 minutes and 12 seconds SPEAKER: Firstly, let’s quickly recap why nutrition is so affected by emergencies and why it’s a priority issue. And this framework by the UN nicely shows the many ways in which an emergency can have all kinds of downstream impacts on populations, on households, and ultimately, individuals. For example, war causing destruction of infrastructure, loss of essential services, which impact on households in terms of lack of access to food, lack of water, hygiene, sanitation, all of which impact on individuals and cause increased risk of malnutrition, disease, and ultimately death. Under-nutrition in all its many forms underlies always half of under-5 child deaths. That’s about 3.1 million deaths per year. But an important subset is a specific type of malnutrition– severe acute malnutrition.

Skip to 1 minute and 6 seconds And this affects only some 19 million children worldwide but causes anywhere from 500,000 to 2 million deaths per year. So very, very important. Has a very high case fatality, and therefore, it’s a major priority in emergency situations. The historical challenge of treating SAM was that the specially formulated milks needed to treat children were often only accessible in feeding centres like the one in this hospital in Malawi. So these centres were few and far between and often difficult to get to. They involved travelling long distances on often poor roads where transport was either just not available or hard to afford. It involved being stuck on the ward for days to weeks while the child was treated.

Skip to 1 minute and 50 seconds And this has all kinds of implications for other children who are left at home, for the mother not being able to work the land and do all the other things that needed doing at home. So there’s a high opportunity cost and financial cost of attending. And carers, unsurprisingly, often came late when children were sick, as well as malnourished, and hence, hard to successfully treat. In the 1990s, the World Health Organisation and others led an important programme to improve quality of care in such feeding centres.

Skip to 2 minutes and 20 seconds However, even if better treatments resulted in 100% cure for those admitted, a major problem was coverage, the fact that most children with SAM in the community never even got identified or admitted in the first place. And you can imagine how a background crisis situation only makes this problem worse, as feeding centres could be tough to get to if there’s, say, a flood or an earthquake or conflict making travel, making access, difficult. And this led to people starting to think about the same problem but from a public health rather than an individual clinical perspective.

Skip to 2 minutes and 56 seconds So if we shift the priority to community outreach and getting numbers in the programme, then as you can see from this diagram, even if we only cure half of the children– so even if the cure is only 50% versus 100% in the hospital– we can still have much more impact on the population as a whole. So this led to birth of community management of acute malnutrition. And the critical elements of this programme are access to care and high programme coverage. So that means getting the most children at risk, the most affected children in the programme as possible. And these two are closely associated with timely treatment.

Skip to 3 minutes and 35 seconds So if coverage is good, if centres are easy to get to, it means that carers are more likely to come at an early stage when, yes, the child may be malnourished, but they’re not yet sick. And they’re much easier to treat at home in the community. CMAM and was made possible by two things, firstly, ready-to-use therapeutic food, which you can see a picture of a child eating here. And this is a nutrient-dense paste based on peanut butter most often and fortified with milk, sugar, and micronutrients. And the other key innovation to move forward was a focus on mid-upper-arm assessment to rapidly and simply identify at-risk and effected children.

Skip to 4 minutes and 16 seconds So by now, there are numerous guidelines and standards going into more details of emergency nutrition, and especially focusing on the management of SAM. In 2013, WHO released new updates on the management of SAM. And this is one of many key resources on the WHO websites. Sphere humanitarian guidelines are another key resource. And these include a chapter on nutrition, which outlines standards for therapeutic feeding programmes and includes targets for coverage in urban, rural, and refugee-camp settings. And these are really helpful field tools. So they’ve already gone through several updates. And the latest 2011 version is currently going another update to continue to improve its usefulness and relevance to field practise.

Skip to 4 minutes and 59 seconds Finally, I want to address the issue of what does this all have to do with NCDs. Well, the important fact is that early-life nutrition not only has short-term implications for disease and death, as we have focused on here, but it also has long-term consequences. There’s now increasing evidence on the developmental origins of adult disease, whereby what happens in very early life– in utero, in the first stages of life– also has long-term effects well into child, adolescent, and later adult life. We, for example, just finished a project in Malawi following survivors of severe malnutrition seven years later. And among the many problems they face is that they’re more stunted than their siblings and community controls.

Skip to 5 minutes and 45 seconds They have less lean muscle mass, as evidenced by weaker hand-grip strength. They’re less active, and they show early risk factors for future non-communicable disease. However, as well as a challenge, this also represents an opportunity to make a long-term as well as a short-term difference. In the first instance, we can focus on the first 1,000 days of life. So this is a critical window of opportunity. So this is from conception to 2 years of age. And it’s a time of rapid growth, rapid development, where we can do lots to support infants and families and do a lot to optimise this early phase of development.

Skip to 6 minutes and 23 seconds But there’s also now interest in the second window of opportunity in adolescence– so when children are going through puberty, through that growth spurt. Adult health and other habits are set during this time. So it’s another key window of opportunity when we can make a difference to future adult health. And finally, it’s important to support mothers and vulnerable adults. So this is important, both in its own right, but also gives them the best chance of having and successfully bringing up healthy children, thus giving the next generation the best start in life.


With everything else that might be happening, good nutrition is essential during an emergency. However, it may come as no surprise that a healthy, balanced diet isn’t all that easy to maintain when faced with the unimaginable stress and upheaval of a humanitarian crisis.

In the video, Dr Marko Kerac discusses why nutrition is such an important issue in crisis settings with a focus on child health, providing an overview of severe acute malnutrition and the value of community management in treating it. He describes the use ready-to-use therapeutic foods for treatment, forms of diagnosis, and the longer term impacts of malnutrition.

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Health in Humanitarian Crises

London School of Hygiene & Tropical Medicine