1. Niger 2005 Dr Milton Tectonidis, London 2006 Operations Questions "…‘regular’ starvation has to be distinguished from violent outbursts of famines…" (Amartya Sen, Poverty & Famines 1981)

2. MSF Maradi Program Ready to Use Therapeutic Foods (RUTF) July 2001-2004 Six outpatient centres One inpatient centre Severe + special cases only 9,632 admissions 83.5% cure rate 2004

3. Clear Signs (W12) March 2005 DAKAR, 21 December (IRIN) Due to poor rains and a severe locust outbreak, Niger this year registered a record grain deficit of 223,487 tons. peak period 2004

4. GAM 19.6 (28.2), SAM 2.9 (4.1) GAM 19.3 (28.5), SAM 2.4 (4.4) U5MR 2.2 – 2.4/10,000/d April - May 2005 EPICENTRE SURVEYS May 25, 2005 MSF Launches Emergency Operation to Combat Malnutrition in Niger

5. Niger Nutritional Surveys January to September 2005

6. NEW SC & OTC (RUTF) + Protection & Discharge Rations March 2005 (Dakoro) May 2005 (Aguié, Tessaoua, Mayahi) TARGETED BLANKET FEEDING late July 2005 (Maradi) late Sept 2005 (Zinder) Angola 2002 Darfur 2004 May 2005 MSF Niger Emergency Strategy Steve Collins

7. Inpatient centres Outpatient points Family rations Targeted blankets Pediatric units Support to OPDs July - October 2005 July 25, 2005 Preventing Severe Malnutrition in Maradi, Niger The first distribution finally took place on Saturday, July 23… October 26 2005 - The Targeted Supplementary Feeding Initiative in Zinder A joint effort of MSF, UNICEF and the World Food Programme.

8. Hunger gap Malnutrition in Maradi 39,158 admissions 60% of admissions in 13 weeks  95% of admissions < 85 cm  40%+ between 75 & 85 cm 91.4% cure rate 3.2% death rate 4.7% default rate 2005 Program indicators 2005

9. A recent survey… confirms that the children of Niger still face high levels of malnutrition. Malnutrition rates range from 9% to 18%, and inadequate infant and young child feeding practices are likely causes. Cultural factors and social behaviours, such as inadequate infant and young child feeding practices, have a major impact... December 2005

10. Malnutrition conceptual framework The most common cause of protein-energy malnutrition is parents’ poor child feeding and caring practices….” FOOD CARE or HEALTH ? World Bank 2006

11. Maradi, Tahoua 1984 1987 Zinder 1997 Maradi 2001 2005 Food availability in Niger

12. Food accessibility in Niger Hunger gap Prices

13. Deluxe WFP ration 2261 kcal 12% proteins 20 % lipids ITEM QUANTITE Cereal 400 gr Pulse 60 gr Oil 25 gr CSB 100 gr Sugar 15 gr Salt 5 gr TOTAL 605 gr Food quality & dietary deficiency monotonous cereal-pulse diets dietary diversification food fortification nutrient supplementation

14. Type I nutrients specific signs of deficiency Type II nutrients growth failure iron, copper, selenium calcium, iodine vitamins A, B, D, E, K nitrogen, essential amino acids sodium, potassium, chloride phosphorus, sulphur zinc, magnesium tissue repair and growth ceases no convalescence from illness anorexia and wasting Nutrient deficiency, growth & malnutrition Mike Golden

15. R. Shrimpton. The timing of growth failure (data from 39 studies) 60 million wasted Nutrient deficiency, growth & malnutrition 130 million underweight 150 million stunted

16. Nutrient dense pastes (equivalent to F-100 + Fe) Ready to eat No added water – contamination free Individualised packaging Increased capacity Outpatient treatment Multiple, decentralized sites Include the "moderates" Improved results Early diagnosis (recruitment) Expanded coverage Quality referral care Ready to Use Therapeutic Foods (RUTF) Designed to encourage rapid weight gain

17. MSF Emergency Nutrition current strategies 2005 blanket feeding 2006 therapeutic feeding 2004 protection rations 2005 discharge family rations therapeutic feeding + targeted food aid

18. General population At risk Acute malnourished general distribution blanket feeding therapeutic feeding Quality Coverage NUTRITION FOOD AID family rations MSF Emergency Nutrition current strategies Angola 2002 TFC + blankets Darfour 2004 TFC + OTC + protection rations (+ blankets) Niger 2005 SC + OTC + protection rations + food ration (+ blankets)

19. ACUTE MALNUTRITION W/H < 80% MUAC < 110 mm Edema COMPLICATEDNON-COMPLICATED ANOREXIA Severe pathology Apathy InpatientOutpatient APPETITE No severe pathology Alert MUAC/edema only ? adjustable thresholds include other age groups Deinstitutionalize Simplify adjust discharge criteria lighten follow-up strengthen referral capacity discharge quickly Acute malnutrition - further work

20. Anthropometry – individual risk acute weight loss RUTF ? Treatment by illness episode ? Extend benefits

21. Anthropometry – individual risk "healthy" reference children rural village age peers child with pertussis poor & incomplete catch-up growth RUTF ? Treatment by illness episode ? Extend benefits

22. Maradi Niger 2005 Up to 25% incidence of severe malnutrition (50% for < 85 cm) South Sudan 1993 Herwaldt et al. 70% U5 < -2 ZS Anthropometry – population risk RUTF ? Therapeutic Blanket ? Extend benefits

23. pregnancy & lactation new therapeutic products & strategies micronutriments +/- calories "acute" malnutrition illness episode convalescence weight loss weaning foods HIV-TB chronic disease ration supplement MSF nutrition RAPID WEIGHT GAIN TARGETED SUPPLEMENT RUTFRUSF Nutrients RUSF

24. Acute weight loss General population Acute malnourished General ration quantity & quality RUTF for rapid weight gain Strategy (who is at risk ?) Targeting (what supplement ?) RUSF for specific target group At risk groups MSF emergency nutrition