Now the question raises, if we find malnutrition, what can we do about it? And in particular, what can we do about acute malnutrition as it is such a potentially life threatening condition? Let's first look at treatment programs. For treatment of acute malnutrition, we need to distinguish for those with severe acute malnutrition, and those with moderate. I just want to say that because of brevity, I'm not going in detail on the micronutrient deficiencies. So as I said, we need to distinguish between those that suffer from moderate and severe acute malnutrition. The severe condition needs always immediate treatment. We try to differentiate children with some severe acute malnutrition with complications from those that have no additional complications. If I speak about complications, I refer to, for example, high fever, no appetite, certain infections, vomiting, excessive bilateral pitting edema, etc. The group with complications needs specialized inpatient care. A hospital setting with good trained staff is a good place. We call such a place stabilization center. In a humanitarian crisis you might have a much higher prevalence of severe acute malnutrition some than normally and physicians need to be taken whether a hospital can deal with all the cases. If there are not enough good referral hospitals such stabilization centers need additionally to be set up close to the areas where these children are. This is often done in collaboration with the Ministry of Health and specialized NGOs. Those that have no additional complications can be treated through out-patient facilities, as they don't need daily intensive medical care. Treatment of children with severe acute malnutrition will be done through specific treatment protocols prescribed by the Minister of Health. These protocols include the use of certain drugs and specific food products. Here's some examples of therapeutic food products that are used in treatment of some of severe acute malnutrition. Specially designed therapeutic milk for those with complications in a hospital or a stabilization center, and ready-to-use therapeutic products for those without complications. This will be done in a community as an out-patient treatment program. A child with moderate acute malnutrition is ideally treated is supplementary food products. We call this targeted supplementary feeding. There's a lot more to say about this, and if you're interest in more detail, the website of the World Health Organizations, is a good starting point and search for treatment of acute malnutrition. Lastly, there is no real consensus when to start large scale treatment programs because it depends on the context. What the food security situation is and how high the mortality rate is. But generally, we can say that when acute malnutrition prevalence reaches 15%, the situation is critical and many lives will be lost if no action is taken. I would like to talk now about how to prevent malnutrition and also how to prevent deterioration of the nutritional situation in a humanitarian crisis. We should look again at the immediate and underlying causes. In a disaster, it will be difficult to address the basic causes with sufficiently quick impact on the prevention of malnutrition. First and foremost, we need to ensure that people's diets meet their nutrients requirements, and diseases are diagnosed and treated. We can do this indirectly through various programs that, if implemented parallel to each other, we'll have a synergistic effect. I'm giving you a few example of some important programs, but I need to stress it down more option than these presented here. An example of program, is the temporary strengthening of primary health care services in existing structures, or new ones. This could be through extra staff support, or through provision of essential drugs. A measles vaccination campaign with vitamin A supplementation can prevent acute malnutrition. Water and sanitation programs, and in particular those that prevent diarrhoeal diseases. This entails, for example, ensuring good sewage systems in an urban setting, the building of latrines, provision of sufficient and safe water for drinking and for washing and hand washing promotion. The prevention of malaria can also be important if relevant to the context. Provision or facilitating adequate shelter is also key to prevent malnutrition as it offers physical protection and can prevent diseases. Another important program that can prevent malnutrition is adequate infant and young child feeding. What we mean by that is that good infant feeding practices are supported. For example, an important activity is to facilitate that those women that breastfeed continued his practice, in spite humanitarian crisis and that they get all the support they need to do this. In practical terms, this could mean that we provide them with safe spaces to breastfeed their infants or that you provide them with nutritional support or with encouragement for breastfeed. In addition, programs that ensure that especially children between six months and two years get adequate care and nutrition, through good complementary feeding are also crucial. Psychosocial care, aimed at caretakers and their children, can also be of great importance. Good childcare can only be done if caregivers are able to function well. Related to the last two examples, it is key that we do not introduce programs that take all the time from caretakers away from their children. This could actually undermine good care practice. In order to prevent or reduce food insecurity, a variety of programs can be implemented. And the previous module, Life Fuels, has listed many of these programs already so I won't refer to these here now. You see that many programs are unrelated to food and yet will have a major preventative role in acute malnutrition. However, I want to mention a few assistance programs that you might come across. That try to prevent malnutrition through direct food assistance. This programs directly aim to address an adequate food intake but also aims to preserve lively food asset for families. General food assistance programs provide food commodities for households that contribute partially or completely to the food needs. It is given to cover a certain time period. General food assistance will be given with the assumption that people have means to prepare and consume their food. If that's not the case, a temporary program providing prepared meals can be installed. This means that cooked food is given to certain groups of people that are identified as particularly vulnerable, and who have limited means to actually prepare their food. This can be done in the immediate aftermath of an earthquake or a flood. You might remember the Syrian refugee and migrant crisis, where thousands of people arrived in Greece without anything. Prepared meals were provided to many of the new arrivals. This is sometimes also done in other situations when refugees arrive in transit centers across borders, just as a temporary measure. Blanket supplementary feeding programs aim to prevent acute malnutrition from worsening in specific groups, such as young children and Pracento lactating women. This program is often lasting not more than few months. Micronutrients supplementation can be necessary if the general food rations are inadequate or and there is a high prevalence of micronutrients deficiency in the population. This supplementation can be done through powders or pastes or tablets. No matter what program is implemented, the impact of the programs on prevention of acute malnutrition depends on the most likely causes. And obviously, you need also to take into account the needs and preferences expressed by families affected. This means that there is a need for thorough assessment which includes causal analysis before any intervention can be designed and implemented. I remember having worked in many humanitarian crisis that malnutrition is rarely caused by one factor. This means you need programs that address more than one cause to have an impact. For example, not too long ago, I was in South Sudan and the malnutrition prevalence was very high and the causes were combination of viral diseases, food insecurity, very weak primary healthcare system, to name a few. Addressing just the food security would not have had sufficient impact alone, we really need to address all causes to have an effect. I would like to give you now some more practical examples from my experience in preventing malnutrition in humanitarian crises. There is no one way to do this. I have been engaged in programs that worked with so called baby tents, to prevent malnutrition among infants. These baby tents provided safe haven for breastfeeding mothers who are encouraged to continue this good practice, despite the fact that these mothers were in great distress. I saw this in Haiti after the earthquake. But you can also imagine how they can help refugee women. Baby tents can also be used to provide these breastfeeding mothers counseling or nutrition dense meals or drinks, so they remain in good health themselves. I have seen also programs that encourage small scale growing of nutrient rich vegetables and herbs for families affected by HIV. The setup of the program was that elderly and even children after school could easily work in it with minimal physical input, and still have enough produce to help them to have an adequate diet. I saw these programs in Lesotho and Swaziland. And they contributed to increase of intake of micronutrients. I saw programs that improved water points for livestock in various African countries. The points ensured that the areas for drinking water for animals and humans were separated to minimize the chance of contamination of drinking water for humans by animal feces. This reduced the incidence of diarrhoeal diseases, and subsequently it reduced the risk of becoming malnourished. I also remember a program of providing resources for reestablishing a bakery that was destroyed after a bombardment. This was in Europe. As bread was an important staple food there, this bakery and the provision of nutrient enriched flour fulfilled an important nutritional purpose. I also know of a program in the Americas. It was a completely different program in a country heavily affected by conflict. Citizens had to go Recule through many mostly informal checkpoints and at every checkpoint, they were asked to give something of the food they carried to the people that controlled these checkpoints. This was a sort of extortion, you cannot pass if you don't give us something to eat. This practice impoverished many people with risk to food and security and malnutrition. A humanitarian organization held many dialogues with those that controlled these informal checkpoints and worked on a deal to stop this practice. They succeeded and this had a positive effect on the nutrition and well being of the citizens. As you can see there are many examples of programs that would all somehow fit in a conceptual framework for malnutrition. The examples contributed directly or indirectly with programs preventing acute malnutrition. I would like to summarize now a few of the main learning points of this module on nutrition. The risk of malnutrition can be very high in a disaster context and acute malnutrition and micronutrient deficiencies are a particular cause of concern in humanitarian crises. Malnutrition is directly caused by inadequate intake of food and/or by diseases. And the underlying courses are linked to food insecurity, inadequate care environment and/or public health problems. Everybody can be affected by malnutrition in a disaster, but the impact can differ. Children are particularly vulnerable to malnutrition. There are different programs that can be implement to treat acute malnutrition. Especially severe acute malnutrition needs immediate and specialized care because of a high risk of mortality. Depending on the main causes of malnutrition there are different programs that can prevent deterioration of the nutritional situation in a humanitarian crisis if timely implemented. Those programs can vary from food to non-food related interventions. We have come to the end of this module. I hope I was able to bring over the notion on how important nutrition can be in a humanitarian crisis. Just look at the current humanitarian crisis that occurred today in the world. You will see that many will have malnutrition as a public health problem. I hope that this module shaped your mind more on this topic. And that whenever you face nutritional problems, you will think of this module, and especially of the conceptual framework. Which is a tool to both help you understand malnutrition but also to help finding ways to address it.
