Hi, I'm Leisel Talley and I'm an epidemiologist in the Emergency Response and Recovery Branch at the US Centers for Disease Control and Prevention. I'm also adjunct faculty at the Rollins School of Public Health at Emory University. I have 16 years experience working in humanitarian emergencies on everything from rapid assessments, outbreak investigations, surveys, capacity building, program evaluation, research and technical assistance. All of this work has been in the nutrition sector, and more specifically focusing on acute malnutrition in infant and young child feeding and emergencies. This lecture is on the subject of nutrition in the context of humanitarian emergencies, the burden and the consequences. You may have heard people talk about malnutrition, which, in technical terms, is a state of physiologic disruption caused by inadequate nutrition. This means that there's an imbalance between a person's nutritional intake and his or her nutritional needs, resulting either from overconsumption or underconsumption of nutrients. Acute malnutrition involves rapid weight loss in an individual. These individuals are simply too thin for their height or their length. Sometimes it's referred to as wasting. There's also a form of acute malnutrition called kwashiorkor, which involves nutritional edema, swelling from excess fluid leaking from blood vessels. So what is a burden of acute malnutrition? An estimated 52 million children under five years of age are acutely malnourished or wasted. 33 million of which are moderately malnourished, and 19 million are severely malnourished. The difference between moderate and severe wasting is the severity of the condition of the child. Currently we reach less than 15% of these children in treatment. Children with acute malnutrition are between 4.5 and 9 times more likely to die, and up to 2 million children die of severe acute malnutrition annually. Because of the risk of mortality and the rapid deterioration children can experience, levels of acute malnutrition in children under five are often used as proxy indicators for determining the severity of a crisis. A child can lose a significant proportional of their body weight in a very short time. When 15% of children under five are acutely malnourished, we determine this to be a critical situation. And enact programs to reduce morbidity, mortality associated with acute malnutrition, and to prevent further deterioration of the population. While acute malnutrition occurs in stable settings, a quarter of acute malnutrition occurs in humanitarian settings. Halfway through 2016, 95.4 million people across 40 countries were affected by humanitarian emergencies. An individual's and population nutrition status is influenced by multiple factors on multiple levels. We often think about nutrition using the nutritional conceptual framework, a tool that's been in place for 25 years and adapted over time. Looking at the outcome of undernutrition or acute malnutrition, we can see what are termed the immediate causes. These are influencing the actual physiological aspects of acute malnutrition. Disease and inadequate food intake are what people most often associate with acute malnutrition. These two immediate causes are incredibly important. An imbalance in calories consumed and calories expended will lead to a negative state. During infection, an individual's nutritional requirements increase. For example, fever increases metabolism, thereby increasing your caloric need. However, anorexia, or the lack of appetite often occur in illness, further reducing the caloric intake. This leads to an infection-malnutrition cycle, whereby malnourished individuals are more prone to infection and infection leads to malnutrition. This cycle continues until it's broken or death occurs. The next level of influencing factors are called the underlying causes. This often come into effect before the immediate causes. First, let's think through household food security. It's important to remember that food security isn't just the availability of food but it also includes access to food both in the market and utilization of food at the household and individual level. There are times when there may be no food available. For example, in a famine context or the end of the lean season when all of the household food stocks have been consumed prior to the harvest. This is an availability issue. In other contexts, markets may be full of commodities. However, a household may not have the purchasing power to access these foods. Likewise, there maybe household dynamics which influence how food is shared within the household. In all of these contexts, food security directly impacts dietary intake on the immediate level. Inadequate care refers to how young children are fed and cared for. Here we tend to think about infant and young child feeding practices. We see disruption in feeding practices during emergencies for several reasons. For example, children may be orphaned as a result of a natural disaster, like the earthquake in Haiti in 2010. These infants and young children may not have access to their regular source of nourishment if their mother was killed or maimed. We may also see large populations of infants who are artificially fed, using breast milk substitute prior to the shock or emergency, who now don't have regular access to formula. As is the case within Syria, and refugees fleeing the conflict. Artificial feeding increases the risk of morbidity and mortality, specifically from diarrheal disease, pneumonia, and acute malnutrition. Artificially fed infants in emergencies have an even greater risk. Not only because they aren't breastfed and protected by the immune properties of breast milk, but because of poor hygienic conditions in which formula may be prepared. And oftentimes, improper formula preparation. Older children are also at risk, as there may not be an appropriate complementary food available in emergencies. Finally, caring practices of the child may be affected as well. In addition to nourishment, children need proper emotional support and stability. Caring practices may be altered as women search for work or face their own mental health challenges. Inadequate caring practices affect dietary intake as well as increasing the risk of disease. Now, let's move on to unhealthy household environment and lack of health services. Unhealthy household environment includes shelter, sanitation, and hygiene. Displaced populations often lack appropriate shelter, which can have a direct impact on the health and nutritional status of individuals. The most pronounced example is with cold temperatures, as ambient temperatures decrease and individual's caloric needs increase. Think about being cold and shivering. Your muscles are generating heat and, in order to do this, they're expending energy. Access to sufficient water, sanitation and latrines is a significant issue in emergencies. This can increase the spread of diarrheal disease. Diarrheal disease can result in rapid weight loss, and repeated episodes of diarrheal disease can have an long term impact on the growth, and development of young children. Health services may have been poor prior to the emergency, and may not be available at the onset or even remain limited over time. Crowding within camps and sites can further increase the transmission of disease. Preventive health services, such as immunization, are often not available, but are a significant priority. Measles and malnutrition have a synergistic relationship, whereby malnutrition increases the risk of measles, and measles increases the risk of acute malnutrition. Curative services are equally as important to provide prompt treatment. These aspects of shelter, sanitation, hygiene, and access to health services directly factor into the risk of disease. Some additional underlying causes, but perhaps at a more distant level, are factors such as income, poverty and assets. All of these affect and drive food insecurity, inadequate care, unhealthy household environments and a lack of access to health care, just as all of these factors impact overall nutritional status. Finally, there are the basic causes. In emergency settings we really can't address these issues. These are longstanding issues at the political, economic and social level. For example, marginalization of ethnic or religious groups on any of these levels. It may also include the overall development and infrastructure in a given country. These all affect populations and individuals, but require more in-depth programming, and larger scale interventions. What's important to remember about acute malnutrition is that factors that drive individuals to a state of malnutrition do not vary whether a child's in an emergency or a non-emergency setting. All of these factors come into play in stable settings, and that's why we see large numbers of malnourished children globally. What is different is the context and the magnitude of the situation. In emergencies, there's a simultaneous intensification of the driving factors of acute malnutrition in an already fragile setting. Many, if not all of the factors, may be affecting nutritional status. But an additional shock, like displacement, crop failure, or large disease outbreak exceed the capacity of the individual, household or population to effectively respond. Ideally, as with all public health models, prevention is the best approach. If we can intervene at the level of underlying causes, we can reduce morbidity and mortality associated with acute malnutrition, even in humanitarian emergencies. We can also work to increase the resilience of fragile, at-risk populations to respond to shocks. Understanding what is driving acute malnutrition in each context is critical to designing an effective response.
