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Médecins Sans Frontières

  1. Top of page
  2. Médecins Sans Frontières
  3. Tracking Child Health and Survival
  4. Providing Hospital Care
  5. Moving Out to the Community
  6. Conclusion
  7. References

In 1971, a group of French doctors and journalists created the international medical organization, Médecins Sans Frontières (MSF; Doctors without Borders). Having witnessed the starvation of thousands of men, women and children caused by blockading forces during the Biafra War, they aimed to create a medical organization that was able to speak about atrocities and abandon the concept of silence that had until then defined humanitarian action. MSF is today the world's largest independent medical humanitarian organization.

Over the past four decades, MSF has provided medical assistance in some of the world's largest humanitarian crises, including those in the spotlight and those the world chose to forget. Famine in Ethiopia, genocide in Rwanda, conflict in Afghanistan and the recent earthquake in Haiti are only a handful of contexts where MSF teams have provided lifesaving medical care. Today, there are over 25 000 field staff providing care in about 400 medical programmes in over 70 countries.

MSF Australia was established in 1995 and provides medical and non-medical field staff and funds; 168 Australian staff were sent to the field in 2011 alone. The Project Unit, with a team of seven health professionals, was established in 2004 to provide medical expertise and operational support to field projects in two thematic areas: paediatrics (including neonatal care, nutrition and paediatric tuberculosis and HIV) and women's health. Paediatric care, at the core of Médecins Sans Frontières' activities, is provided in two formats: (i) hospital care, where treatment is given to hospitalised children, such as children with severe complicated malnutrition, severe malaria, tetanus, pneumonia and sepsis; specialised care is offered for burns and surgery and essential newborn services where we provide obstetric care; and (ii) out-of-hospital care, including general health care with curative and preventive services in health centres and the community, such as vaccination and nutrition programmes.

Tracking Child Health and Survival

  1. Top of page
  2. Médecins Sans Frontières
  3. Tracking Child Health and Survival
  4. Providing Hospital Care
  5. Moving Out to the Community
  6. Conclusion
  7. References

In 2010, it is estimated that nearly 21 000 children died per day. Globally, the number of deaths among children under 5 years of age has fallen from 12.4 million in 1990 to 7.6 million in 2010,[1] but high mortality rates persist in sub-Saharan Africa where one child in eight dies before the age of 5. About 40% of deaths of children under 5 years old occurs within the first month of life, and some 70% occur within the first year of life.

Both malnutrition and malaria are important contributors to child morbidity and mortality. Acute malnutrition affects more than 65 million children under 5 years old worldwide, and with important bidirectional interactions with immunity and infection, is estimated to contribute to one-third of all deaths under the age of 5.[2] Malaria, accounting for 1.24 million deaths world-wide in 2010, accounts for nearly one-quarter of all child deaths in sub-Saharan Africa.[3]

Providing Hospital Care

  1. Top of page
  2. Médecins Sans Frontières
  3. Tracking Child Health and Survival
  4. Providing Hospital Care
  5. Moving Out to the Community
  6. Conclusion
  7. References

In settings of limited resources and health infrastructure, a priority for MSF has been to support existing hospital care services. For example, in the Koutiala district of Mali, MSF provides paediatric and nutrition care in collaboration with the Ministry of Health. In 2011, this programme provided hospitalisation for more than 10 000 children – in the peak season, the number of children hospitalised exceeded 1000 per month. Significant increases in morbidity and hospital admissions are anticipated from August to November due to seasonal food shortages and malaria transmission, and the limited resources of the programme can be stretched. To accommodate the patients during this time, tents are raised in the hospital courtyard to increase the effective bed capacity to 370, representing the largest paediatric ward in the country (Fig. 1).

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Figure 1. Crowded paediatric ward in Rutshuru Hospital, Democratic Republic of Congo, © 2009 Myrto Schaefer.

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Many of the children arrive in a very severe condition and in shock. Providing appropriate diagnosis and treatment to these severely sick children is a real challenge, not only due to limited resources in these settings but also due to lack of evidence appropriate for these settings. As suggested in the recently published study on fluid resuscitation of children with severe infection in East Africa where bolus increased the risk of 48-h mortality,[4] the safety and efficacy of transferring traditional protocols from resource-rich to resource-limited contexts cannot be presumed.

With regard to malnutrition, there are additional challenges related to hospital management of complicated cases (Fig. 2). Children with severe acute malnutrition often present with immunodeficiency and metabolic, electrolyte and multi-organ dysfunction, but strong clinical evidence on how to address these complications, as well as diagnostic and therapeutic capacity, is limited. Inpatient management of severe acute malnutrition requires treatment with therapeutic milk eight times per day and necessary medical input, such as intravenous antibiotics and fluids, blood transfusion,anti-helminthics, oxygen and, most of all, intensive nursing care. Hospital care for the treatment of severe acute malnutrition, previously the standard of care for all cases, is resource-intensive, introduces an increased risk of nosocomial infection and represents a high burden to care givers, who often must stay in hospital away from other children and household responsibilities. Hospital care is also limited by the relatively small number of children that can be treated with finite bed capacity and resources.

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Figure 2. A malnourished child is weighed by the MSF team in Zinder, Niger, © 2010 Jean-François Herrera.

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Malaria-related complications are also highly prevalent in the hospitals where we work. In Mali in 2011, more than 80% of hospitalised children had malaria-associated complications, such as cerebral malaria or severe anaemia. In Koutiala, more than one in five hospitalised children required transfusion (as indicated with a haemoglobin <4 or <6 g/dL in presence of clinical symptoms[5]).

Moving Out to the Community

  1. Top of page
  2. Médecins Sans Frontières
  3. Tracking Child Health and Survival
  4. Providing Hospital Care
  5. Moving Out to the Community
  6. Conclusion
  7. References

It is obvious that a hospital-based response cannot be the singular answer to tackling childhood illness. Hospital-based care requires large financial, structural and human resource inputs, as well as presents important challenges to care givers balancing other household needs. As many children still die at home, out of reach of centralised hospital care, additional effort to increase prevention and treatment at the community level is needed to have an impact on childhood morbidity and mortality. Community-based care has the potential to reduce pressure on hospital systems, allowing for a higher quality of care for those complicated cases that remain, but also to identify and treat children early before their clinical condition deteriorates to very severe levels.

In nutrition, the community-based approach has worked well. In the early 2000s, the non-governmental organizations Valid International and Concern Worldwide pioneered a new community-based approach to the management of acute malnutrition. This approach allowed children with an uncomplicated presentation of severe acute malnutrition to be treated at home with the provision of ready-to-use therapeutic food (RUTF); only those children without an appetite or with medical complications such as severe infection now require referral to hospital care (Fig. 3). Key to the community-based approach was the development of RUTF, an energy-dense, micronutrient-enriched paste with a nutritional profile similar to the traditional milk-based diets used in hospital-based therapeutic feeding programmes. As the name suggests, RUTF is ready to use, requiring no cooking or preparation, and containing virtually no water, they are resistant to bacterial growth and do not require refrigeration. In 2005, MSF used a community-based approach with RUTF to provide treatment to over 60 000 children in Niger with severe acute malnutrition – a sixfold increase in the number treated by MSF in 2004, when all severely malnourished children received hospital care according to the previous guidelines.[6] After this initial success, demonstrating that coverage could be dramatically increased while maintaining high rates of recovery, use of this community-based model has grown in MSF: in 2010, MSF treated over 300 000 children with severe acute malnutrition globally in over 130 nutrition programmes.

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Figure 3. Nutritional therapy for severe acute malnutrition with ready-to-use therapeutic-food, Somalia, © 2011 Yann Libessart.

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For malaria, community-based approaches are also promising. In the past two years, MSF provided community-based malaria diagnosis and treatment in 17 villages in the district of Koutiala during the malaria peak season using community health workers. In 2011, MSF thus treated 8744 children for malaria in their villages and referred 237 children with severe malaria to health structures for further care.

An additional strategy that has gained momentum in recent years is seasonal malaria chemoprophylaxis (SMC; previously called intermittent preventive treatment for children). This refers to the intermittent administration of a full treatment course of an antimalarial medicine during the malaria season to prevent malarial illness by maintaining therapeutic antimalarial drug concentrations in the blood throughout the period of greatest malarial risk. Several recent studies in West Africa have shown promising results,[7, 8] with high protective efficacy rates against uncomplicated (protective efficacy 83%, 95% confidence interval (CI) 78–87) and complicated malaria (protective efficacy 76%, 95% CI 46–89%).[9] In 2012, MSF hopes to collaborate with the Ministry of Health of Mali to introduce SMC, as well as using community health workers in Koutiala district to reinforce community-based diagnosis and treatment (Fig. 4). It is anticipated that this combination of approaches will not only help to prevent and treat uncomplicated malaria at the community level, but also reduce hospital admissions for severe malaria-associated complications.

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Figure 4. A child receives a rapid diagnostic test for malaria, Sierra Leone, © 2009 Emily Linendoll.

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Conclusion

  1. Top of page
  2. Médecins Sans Frontières
  3. Tracking Child Health and Survival
  4. Providing Hospital Care
  5. Moving Out to the Community
  6. Conclusion
  7. References

Community-based approaches are promising, providing the advantage of treating children earlier and closer to home, but it would be naïve to presume that challenges do not remain – great needs persist for increased resources, better diagnostics, and additional context-specific research, specialists and training. Despite these challenges, MSF's experience continues to show that it is possible to treat large numbers of children well with fewer resources than what is considered ‘standard of care’ in resource-rich countries. Every day, we fight an uphill battle in challenging circumstances but we know lives can be saved. To keep more children alive and well, discussions that push boundaries must continue in order to improve protocols and innovate delivery strategies.

References

  1. Top of page
  2. Médecins Sans Frontières
  3. Tracking Child Health and Survival
  4. Providing Hospital Care
  5. Moving Out to the Community
  6. Conclusion
  7. References
  • 1
    United Nations Inter-Agency Group for Child Mortality Estimation. Levels and Trends in Child Mortality: Report 2011. New York: United Nations Children's Fund, 2011.
  • 2
    United Nations Children's Fund. Tracking Progress on Child and Maternal Nutrition. New York: UNICEF, 2009.
  • 3
    Murray C, Rosenfeld L, Lim S et al. Global malaria mortality between 1980 and 2010: a systematic analysis. Lancet 2012; 379: 413431.
  • 4
    Maitland K, Kiguli S, Opoka R et al. Mortality after fluid bolus in children with severe infection. N. Engl. J. Med. 2011; 364: 24832495.
  • 5
    World Health Organization. Pocketbook for Hospital Care for Children. Geneva: World Health Organization, 2005.
  • 6
    Tectonidis M. Crisis in Niger – outpatient care for severe acute malnutrition. N. Engl. J. Med. 2006; 352: 224227.
  • 7
    Dicko A, Diallo AI, Tembine I et al. Intermittent preventive treatment of malaria provides substantial protection against malaria in children already protected by an insecticide-treated bednet in Mali: a randomised, double-blind, placebo-controlled trial. PLoS Med. 2011; 8: e1000407.
  • 8
    Konate AT, Yaro JB, Oue'draogo AZ et al. Intermittent preventive treatment of malaria provides substantial protection against malaria in children already protected by an insecticide-treated bednet in Burkina Faso: a randomised, double-blind, placebo-controlled trial. PLoS Med. 2011; 8: e1000408.
  • 9
    Diallo D. Seasonal malaria chemoprevention in children for malaria control in the Sahel and sub-Sahel areas of sub-Saharan Africa. Abstract presented at: 2011 International Symposium on reducing child mortality, 15 November 2011, Melbourne, Australia.