Missing link in Kenya's response to malnutrition

“She may never know how close she came to death,” Maurine Njeri, a nutritionist at Wamba Health Centre in Samburu East says, glancing at Baby Asha with a smile playing at the corner of her mouth.

In her hand is a file, the documentation of every intervention she has given the nine-month-old girl, helping snatch her from the claws of death.
Ms Njeri found the baby all skin and bones in Wigama Village during an outreach programme to deliver health services to far-flung areas of Samburu County.
Even before she took the baby’s weight and height, the protruding belly and visible ribs pointed to a case of severe malnutrition. Famished and weak, Baby Asha could barely let out more than a muffled cry.
Her mother, who got pregnant in her teens, left the baby with its grandmother at three months, an age at which a baby should be exclusively breastfed until six months, followed by complementary foods and continued breastfeeding for at least two years.
NUTRITIONAL FOUNDATION

But Baby Asha’s mother had to leave for Isiolo to fend for the family, leaving her child out of the group of six in 10 children who are exclusively breastfed as recommended, according to the Kenya Demographic Health Survey of 2014.
The baby not only missed out on this important nutritional foundation, but also complementary foods that were hard to come by, in one of the 23 arid and semi-arid counties that are ranked as the most food insecure.
When her body did not get food and in turn glucose, the body’s main source of energy, it began to break down stored fat into energy and chemicals called ketones, which appear in blood and urine.
As brain cells and red blood cells cannot metabolise ketones, to survive, they get their energy by breaking down muscle.
If this energy is not replenished, organs weaken, stop working and the child eventually dies from organ failure and other complications.
STABILISATION

To prevent this, Ms Njeri asked the baby’s mother to take the child with her for hospitalisation. In hospital, she was fed with F75, a ready-to-eat therapeutic food, to help stabilise her organs, before graduating to F100. After considering the upper body circumference, height, weight and age of the child, nutritionists use a formula to calculate the portions of food to be given.
Gladys Mugambi, the local focal point for the UN-backed Scaling Up Nutrition global movement, told HealthyNation that children with malnutrition are categorised as those at risk, moderate and severe, and each category is handled differently by nutritionists, who serve them different portions of the therapeutic meals.
“When a baby is severely malnourished, you cannot put them on high-calorie food until they are stable. That is why they are treated with F75 first,” explained Ms Mugambi.
Within days of starting therapy, Baby Asha recovered 10 per cent of her body weight, and in six months, she had morphed from a gaunt baby to a bubbly nine-month-old.
A joint nutrition assessment conducted by the county departments of health, Unicef and nine other aid organisations, found that in 2017, more than 73,000 children were severely malnourished and at risk of dying.
SEVERE ACUTE MALNUTRITION

Severe acute malnutrition is characterised by very low weight for height and severe wasting, and according to the World Health Organisation, it is directly and indirectly responsible for 35 per cent of deaths of children under the age of five in the world.
The assessment found that severe acute malnutrition – the most dangerous form of hunger – had gone up four-fold in a year, from a manageable 2.3 per cent to 8.3 per cent. East Pokot had one of the highest rates of severe acute malnutrition (nearly six per cent), followed by Mandera (five per cent) and West Pokot (3.2 per cent).
Despite the relentless cases of malnutrition, nutritionists say that national and county governments have approached the issue from the aspect of the quantity of food, rather than as a complex problem that requires medical attention.
Michael Lokon, a nutritionist involved in outreach programmes in Samburu, told HealthyNation that it goes beyond giving relief food, as nutritionists encounter many cases that need constant monitoring even after food is supplied.
In Turkana County, one of those that are affected most by malnutrition, the county government allocated more than Sh600 million in its 2018/2019 budget to address undernutrition by supporting farming. This is in line with the national approach to food security, which as entrenched in Kenya’s development agenda, leans more on agriculture, ignoring the developmental challenges – the proverbial grey matter infrastructure – that face a child who does not receive all the required nutritional components in the first 1,000 days of life after birth.
These nutrients needed for the development of the brain are ideally gotten through breast milk from the children’s mothers, but in some cases, the mothers themselves are undernourished.

NUTRITIONAL ISSUES
Further, last month during the launch of a report about food choices in Kenya and Ghana, epidemiologist Gershim Asiki said that feeding programmes in food-insecure areas are often targeted to encourage enrolment in schools, rather than to address the nutritional issues of children.
Malnutrition is often made worse by cultural practices. Samburu County Nutritionist Coordinator Delphina Kamaan, told HealthyNation that in some communities, pregnant women are barred from taking the foods they desperately need such as milk, eggs and meat.
Ms Njeri, the nutritionist at Wamba Health Centre, has also encountered children who were being fed goat milk days after birth because their mothers believed that breast milk was not enough.

The other component is lack of adequate human resources. There are 3,066 nutritionists and dieticians; 4,430 nutrition and dietetic technologists and 813 nutrition and dietetic technicians according to data from the Kenya National Bureau of Statistics; while data from the Ministry of Health indicates that there are about 1,300 nutritionists employed by the government to serve the entire country.
INADEQUATE HUMAN RESOURCES

Despite the complexity involved in managing cases such as Baby Asha’s, some counties, such as Samburu and Isiolo, rely on community health volunteers to respond to acute and chronic malnutrition.
“There are many nutritionists but few are employed because employers do not understand what exactly nutritionist can do,” said Ms Mugambi, the former head of nutrition at the Ministry of Health.
As of February 2019, Samburu County has employed on 14 nutritionists to manage malnutrition, diabetes, HIV/Aids and other conditions, but the county head of nutrition Ms Kaaman said that the number only increased from four after advocacy.
Ms Kaaman said that the county needs at least 50 such workers, but there aren’t enough nutritionists to cover the expanse of Samburu County, and some like Ms Njeri and Mr Lokon are volunteers, receiving support from Action Against Hunger, a non-governmental organisation which runs the outreach services in coordination with the county health department. The same scenario plays out in Isiolo, Turkana and Mandera.
In places the nutritionists cannot reach, the county relies on community health volunteers to inform and educate the community, and they do come in handy in supporting malnourished mothers who are not even aware of where they can go for help.
Lenaisho Norparaku, is one such woman, who delivered her twins prematurely because she was not well-fed.
After being discharged from hospital, she relied on donated food supplements to produce enough milk for exclusive breastfeeding.
It was a community health volunteer who identified her and referred her to a nutritionist so that her six-month-old babies could get help, and with the therapeutic ready-to-eat foods, the babies recovered in four months.

COMPLEX SCIENCE
The community health volunteers use coloured cards to diagnose malnutrition and videos to teach mothers, many of whom can neither read nor write, about the interventions they need for their babies and how to use therapeutic foods such as F75 or PlumpyNut. While the use of community of health volunteers is thoughtful, it has raised questions over the simplistic approach to nutrition as the provision of food, any food, at any amount, despite it being a complex science that exists in the context of other societal issues.
This complexity led the Kenya Nutritionists and Dietician Institute which develops the training curriculum for this specialist health workers at university, diploma and certificate level to introduce a year of internship just like for doctors, nurses and pharmacists, seeing as nutritionists and dieticians are also involved in the clinical management of patients.
Official apathy has pushed nutritionists to the periphery of health, which could be why a 2018 study showed that no African country is expected to reach the UN target of ending childhood malnutrition by 2030.
The research, comprising of two papers published in the scientific journal Nature, identified local hotspots for poor child nutrition and low education levels across 51 African countries.
By using maps of local health and education data, researchers identified variations at state and county level that were missing in previous comparisons. Kenya was among these hotspots.