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Mal-Mal approach to malnutrition

By John Oommen

The determinants of nutritional status are different from place to place. The Mitra programme in adivasi areas of Orissa where 35% of children would die before the age of five, found a strong correlation between prevalence of malaria and malnutrition. Treating children for malaria immediately saw their weights jump. Identifying and dealing with specific local factors could change the game for malnourished children and communities

I am a community health physician and I have been working with a predominantly adivasi community in and around Bissamcuttack in Rayagada district of Orissa since 1993. The Christian Hospital, Bissamcuttack, is a 200-bedded, multi-disciplinary hospital that has been serving this vulnerable and needy region since 1954. The community health department is known as Mitra, meaning 'friend', and standing for 'Madsen's Institute for Tribal and Rural Advancement'. The programme works with around 12,700 people in 53 villages towards a four-fold dream: health for all, education for all, economic security for all, and social empowerment for all. We measure ourselves and our work against the realisation of these four dreams. For example, our infant mortality rate was 201 per 1,000 live births in 1994. We dreamt of a day when it would be less than 60, like they said at Alma Ata. We have now reached 79 -- a long way travelled but a steeper trek ahead of us. The law of diminishing returns means the climb gets steeper on the higher slopes.

Malnutrition is part of our reality -- it's something we see and face each day in children who are thinner than they should be, their potential growth stunted. It is not a cold, academic issue or a distant, emotive bandwagon; not a political football or a tear-jerking fundraiser. It's a 'normal' part of our everyday lives.

Over the years, we have tried our hand at approaching the problem from different angles and we would like to share the ideas that have emerged. We do not claim exclusivity on these ideas, nor do we say that they can be generalised to be applied everywhere; we would just like to add them to the pile of public consciousness.

What do we mean by 'malnutrition'?

Words are very powerful things. They can stimulate our thinking -- or limit it. 'Malnutrition' is a powerful word that stimulates debate, but it means different things to different people. The images it conjures up in our minds are often drawn from BBC pictures of Somalia or Frontline photographs of Gadchiroli. Generally, each person seems to take off in the direction of their professional genes. So, say 'malnutrition' and the nutritionists talk of proteins and calories, zinc and magnesium. The economists chase purchasing capacity, sociologists debate food security, activists raise human rights, and doctors do disease. But in the emotion and din, we forget the fundamental point that this is about a person -- usually a child -- and his or her health and chance at life.

While adult malnutrition is also a reality, for the sake of this discussion I will focus on childhood malnutrition.

Let's begin by stating the obvious, by clarifying what physical malnutrition is as against the more conceptual malnutrition that bandwagons thrive on.

When we talk of 'malnutrition', or 'this child is malnourished', what we usually mean is that the child has a weight or height or mid-arm circumference (or a ratio of weight to height) that is lower than a prescribed age-specific standard. Further, this shortcoming can affect the child's life -- in terms of quality of life, growth potential, ability to combat illness, and life expectancy.

The opposite picture in our minds is of a 'healthy child', typified by the 'well baby' shows or the 'Amul baby' in colloquial parlance (without reference to recent political uses of the term!).

Some basic questions arise.

Who defines normal? What is that based on? Can there be a single 'normal' for all races and genders globally? Will one boy's malnutrition in one community be a girl's 'well baby' status in another?

For many years, most groups have used weight for age as the most common handle for measuring nutritional status. The normal standard used was the 50th percentile of the Harvard standard, the growth curve of the 'middle child' in a large set of 'normal' children in the USA. Any child anywhere in the world at any age from zero to five years was classified in relation to this graph. A weight for age of up to 80% of this curve was considered 'normal' or 'on the road to health'. If you were at 70-80% of this, you were said to have Grade 1 malnutrition; 60-70% was Grade 2; 50-60% Grade 3; and below 50% Grade 4. This graph was used to monitor the growth of children up to the age of five.

More recently, the World Health Organisation came out with a new set of standards based on the weights and heights of children in six countries, including India and Brazil. These WHO standards provide separate graphs for boys and for girls, as their normal growth patterns are different. Using the concept of a Bell curve, the mean or average weight of all the healthy children studied is used as the 'normal'. The weights of the children to be monitored are plotted on the graph in terms of their variation from the normal. Based on these standards, a child's weight for age is classified into 'normal', 'moderately underweight' and 'severely underweight'. The cut-offs are based on standard deviations (SD), a statistical concept that measures variation from the normal. Children with weights that are over three SD away from the normal are called 'severely underweight'. Those between two and three SD are classified as 'moderately underweight'.

Most groups are now switching over to this system, including the Integrated Child Development Services (ICDS), as it is considered more appropriate and correct. The change in system has meant that children can suddenly change categories of health and risk overnight, depending on which growth monitoring card you use. An individual child could be malnourished in the old system, but normal in the new one. From a public health perspective, the move from the Harvard-standard-based cards to the WHO growth standards increases the number of children in the 'normal' zone, and also in the 'severely underweight' zone. The number of children qualifying for special interventions targeted for the severely malnourished increases considerably, as the qualifying weight level is lower than in the previous system.

The Mitra approach

What do you do when you work with a predominantly adivasi community in rural Orissa? Should a child here necessarily measure the same as a child in the USA, Brazil or even Punjab? Evidence suggests that children in all communities, if given optimum conditions and inputs, grow similarly. But what do you tell a mother after taking her child's weight and height about how he/she is doing?

In the '70s and '80s, our founder, Dr Lis Madsen of Denmark, used weight for height squared as her indicator of a child's health or nutritional status in the adivasi community where people are relatively shorter than other communities. She made her own graphs for this.

Then, in the '90s and early-2000s, we took a shortcut. We monitored the growth of our children by recording their weight for age, and used 'road to health' cards based on the Harvard standard. However, we found that children classified as suffering from Grade 1 malnutrition on this basis were not different from those classified as normal in terms of their risk of mortality and their general level of activity. So we clumped them together and decided that it was the children in Grade 2, 3 and 4 that we considered 'at risk' and needing intervention.

In 2007, we revisited our textbook understanding of malnutrition, stimulated by questions from Gayatri Singh, a nutritionist then with Unicef, Bhubaneswar. The wisdom that emerged was as follows:

Our dream is that all children will be healthy and well-nourished. Nutritional status is what we are really trying to measure as an indicator of the health of the child and as a predictor of risk. To keep on track, we need to do growth monitoring -- not just weight recording. We need to move from snapshots to videography, as it were. So the question for this child is not where he or she is on a chart from the WHO, but whether he or she is growing well. Each child becomes his or her own standard in a way. Healthy children grow. Failure to grow or a faltering growth curve is an indicator that something is wrong. Every mother and father should want to check their child's weight each month and compare it with the previous month. We should ask ourselves: Is my child growing enough? We studied available graphs and literature on how much a child normally grows each month; we arrived at a figure of 500 grams a month in the 0-12-month age-group, and 200 grams a month in the 13-36-month age-group. We called that 'adequate growth'.

Our approach is to try to inspire all parents to weigh their children every month. The weight change is calculated in comparison to the previous month's reading using the formula: weight change in grams x 30 divided by the gap in days between weight recordings.

This is to standardise the rate of weight change to a 30-day period for comparability. Children's growth is then classified as 'adequate', 'inadequate', 'zero change' and 'negative change'. A child who has two consecutive negative change readings or three consecutive zero change readings on monthly growth monitoring is considered to be a 'nutritionally at risk child' (NARC) needing intervention. The NARC register tracks these children, listing them when they enter the risk zone and graduating them out when they resume a healthy growth pattern.

The data collated for all children helps tell us the community's nutritional status. We also crosscheck this with the nutritional grades to see if we are going forwards or backwards.

Approaches to reducing malnutrition or improving nutritional status

The nutritional status of a child is a dynamic equilibrium between positive 'pulling-up' factors and negative 'pushing-down' factors. The pulling-up factors include food/nutrient intake and are therefore dependent on a variety of issues like poverty, access, awareness, etc. The pushing-down factors for growth include illness and disease, which can be like a hole in the proverbial bucket. All the water you pour in fails to raise the level inside unless you find ways to plug or minimise the leaks.

When I first began working in community health here, I was surprised to find that a spot check at any given point appeared to show a relatively healthy looking community. Adults and children generally looked well compared to what I was used to in rural Tamil Nadu where I grew up and trained. But a listing of deaths in the last 12 months indicated extremely high mortality levels. It was as if only the fittest survived, and you were seeing only them.

We began with traditional approaches we had been trained to use, and found the solutions we offered (like immunisation) were for problems they did not have, and the problems they had (like overwhelming malaria) were not on our standard menu for community health.

The malnutrition we saw then did not make much sense to us. Here was a community that cared deeply for their children. Since survival was almost a hit-or-miss thing, with 20% of children dying before the age of one and 35% dying before the age of five, babies were not named until they were about two years old -- it made it so much harder to let go once the child had an identity. On the other hand, childcare practices were relatively good -- breastfeeding was early and sustained for two years; the gap between births of children was generally two to three years (unless a child died, in which case the next came faster). And so on. Why were some children very malnourished?

About 10 years ago, we invited six severely malnourished children from our programme villages to the hospital to investigate them for possible disease factors. Four out of the six tested positive for falciparum malaria. There were two who had intestinal parasitic infections like giardiasis and/or amoebiasis in their stool samples. We treated these and put them on weekly chloroquine prophylaxis against malaria. And their weights jumped. The children quickly reversed their sinking growth curves. We tried this with other malnourished children and arrived at a medical treatment package for childhood malnutrition in our area. This was not a research study, just a desperate attempt to keep our kids alive and growing. And it worked. Today we treat nutritionally at-risk children with a medical package that includes treatment for malaria with sulfa-pyrimethamine, followed by three to six months of chloroquine prophylaxis against malaria; a course of metronidazole for intestinal infections; iron and folic acid supplements for anaemia; a dose of Vitamin A; and a course of antibiotics only if an infection warrants it. Children are followed up and graduated from the NARC register once they show adequate growth patterns. The data shows a sharp reduction in the number of children with negative and stagnant growth curves.

Mal-Mal: The missing link between malaria and malnutrition

The 16 districts of Orissa listed as being high burden for malaria are also listed as high burden for malnutrition. They overlap. Could there be a connection? Most studies on the link between the two talk of the effect of the nutritional status of the child on the possible outcome of a severe attack of malaria. Malnourished children are less likely to survive an attack of severe falciparum malaria than their well-nourished counterparts. Very few have asked the reverse question: Can chronic or recurrent malaria be a cause for malnutrition? Any healthcare professional working in high malaria-high malnutrition regions of Africa and India instinctively knows the truth in this. There is already a lot of evidence that maternal malaria can cause low birth weight in babies, hence the strategies for prophylaxis or intermittent presumptive treatment in pregnancy. Why can't this be true for the following years of life too? We believe that reduction of malaria prevalence will cause an improvement in nutritional status in such areas -- both at the individual child level and at the community level. There is a lot of 'asymptomatic' malaria in our areas. But we call it 'asymptomatic' because we think the only symptom for malaria is fever. But malaria also causes anaemia, growth faltering, and less-than-normal performance. And it is well known that malnourished children often do not display fever even with an attack of malaria.

One problem is that we do not know how much malaria there is in India -- our data is so infamously unreliable. The National Vector-Borne Disease Control Programme (NVBDCP) estimates that there are about 1,000 malaria deaths per year in the country. The WHO suggests it could be 15,000-20,000. The Million Death Study published in The Lancet in October 2010 estimated that there could be 200,000 deaths a year in India, with 51,000 in Orissa alone. What do you believe?

The indicators of malaria occurrence commonly used in the national programme (such as annual parasite incidence) are as much an indicator of programme efficiency, staff performance, availability of microscopy services, etc, as they are of the amount of malaria itself. They are all based on the number of positive malaria slide tests in the public health system.

We suggest that the most objective indicator of whether malaria is endemic in a region is the point prevalence of malaria parasitaemia in children under five years in this community; that is, what percentage of children under the age of five tests positive for malaria on a blood test in a mass survey. The approach in high-burden malaria areas would be to test all children for malaria during the high transmission season, and to treat all those who test positive. Active screening and treatment for malaria in children is both a diagnostic and a therapeutic option, on a mass scale, in areas of hyper-endemic malaria -- and that could decrease both malnutrition and malaria in one stroke. Of course, this has to be combined with personal protection measures and other sustained interventions.

This is what we now call the 'Mal-Mal' approach. We offer Mal-Mal camps for children in our project villages where each child has a general check-up, growth monitoring and discussion, treatment of minor ailments, a blood smear for malaria parasites, treatment of all positives with ACT, and access to medicated mosquito nets. We undertake this annual exercise in the peak transmission months, helping detect children with malaria parasitaemia and clearing it with effective treatment embedded within a regular growth monitoring programme.

We would like to share some data from these pursuits.

Question 1: How much malaria is there in reality?

Table 1 provides information from surveys undertaken by civil society organisations in Orissa over the last 10 years that suggests that malaria is not an occasional attack but a fact of our existence -- between 36% and 58.6% of children tested positive for the malaria parasite. It is pertinent to mention here that the 2010 survey by six NGOs quoted here used rapid diagnostic kits, while the other three surveys used malaria microscopy. Microscopy is considered to be the gold standard for diagnosis of malaria, but requires skilled personnel. The rapid diagnostic kits are much easier to do especially out in the field, but are not considered as accurate as microscopy.

Table 1

Question 2: What is the impact of the Mitra approach on malaria prevalence?

The embarrassing fact from Table 1 is that the percentage positivity in Mitra areas appears to have not changed at all between 2004 and 2010. In reality, we had a decrease and then a resurgence. Malaria control achieved is not a permanent state, but a slippery slope that needs continuous effort to sustain.

Since 2010, Mitra has been conducting an annual round of Mal-Mal camps. We begin with the high-burden villages and work our way through 50 villages between July and December, keeping the dates for each village as close to the previous year as possible to decrease seasonal variations. Table 2 provides comparative data for 2010 and 2011, as available this far. Between the two rounds, the Mitra team undertook street plays on malaria, promoted personal protection measures like neem oil and medicated mosquito nets, and provided access to treatment for malaria through mobile clinics and health workers. In addition, the NVBDCP supplied long-lasting, insecticide-treated nets to eight of the 50 villages, besides the other usual programmes.

The table shows that the percentage of children who tested positive for malaria in the mass Mal-Mal survey decreased from 59% to 33% -- a dramatic change in 12 months. This, to a great extent, vindicates the approach used.

Table 2

Results of Active Screening of Children in Mal-Mal Camps of Mitra, Bissamcuttack
(2010 - 2011)

Question 3: What is the impact of the Mitra approach on the nutritional status of children?

Table 3 shows data from a review of 74 nutritionally at-risk children who received the Mitra protocol in 2009. There is a striking shift of children from weight loss and stagnation to adequate growth.

Table 3

The same data set is provided in Table 4 but analysed as mean weight changes.

Table 4

It is evident that clearing or suppressing malaria infection releases the growth potential of children in this hyper-endemic region.

Table 5 looks at data from the regular Mitra growth monitoring programme, in the first year of the Mal-Mal approach. It shows that during the year, the number of children losing weight halved while those with rising growth curves increased sharply.

Table 5


It is said that malaria is a "local and focal" problem -- the epidemiology of malaria differs from place to place. The solutions therefore must also be local and focal; what works in one place may not necessarily work elsewhere. This is true of nutritional issues too. What worked for the children of our area may not be relevant to other regions. There is no magic bullet, or magic RUTF (ready-to-use therapeutic food) for that matter, that can solve all the problems of malnutrition with one stroke. And what we do at Mitra is not in isolation either. The Mal-Mal camps are part of our malaria programme that includes medicated mosquito nets, malaria education campaigns, etc. This is situated in, and not excluded from, the initiatives of the NVBDCP. Similarly, our nutrition strategy is part of our larger community health programme. But these children are also beneficiaries of the state ICDS. Our aim was not to do research; our aim was to add value to what exists, to try and keep our children alive and well.

What then is the take-home message?

Malnutrition is a word with many connotations. We need ultimately to think of nutritional status. We need to consider the local epidemiology of malnutrition and other childhood issues in the specific region. The determinants of nutritional status can be very different from place to place. Identifying specific local factors and strategically dealing with them will help change the game for the individual child and the community. We cannot afford to suspend our intellect when we get into programme implementation mode. We need to constantly ask 'why'. We need to keep our processes subservient to our desired outcomes; we need to make the goals dictate the methods.

And that is true in all of public health.

Acknowledgement: The ideas and thoughts in this article are from the shared experience of the Mitra team, over many years of community work together. I wish to acknowledge the encouragement and stimulation of the Technical and Management Support Team, Government of Orissa, of which I am a member. The team, along with the Department of Health and Family Welfare and the Department of Women and Child Development, Government of Orissa, has pursued the idea, and hosted a Mal-Mal workshop in May 2010 to gather evidence on Mal-Mal. They have constantly encouraged us at Mitra to introspect and share our learning. We at Mitra also wish to acknowledge the support and partnership of the Sir Dorabji Tata Trust, Mumbai, that is currently sharing our journey. SDTT helped us set up a malaria resource centre, and, together, we are helping NGOs in south Orissa conduct community-based malaria control programmes in their areas

(John Oommen is a community health physician trained at the Christian Medical College, Vellore. He has been working with the predominantly adivasi community in and around Bissamcuttack in Rayagada district of Orissa since 199)

Infochange News & Features, July 2012