Eliminating Malnutrition in Rwanda

While on an official visit to my district in January, Rwanda’s Prime Minister Pierre Damien Habumuremy vowed to eliminate malnutrition across Rwanda in just six months. 

I applaud the Rwandan government for vocalizing their commitment to eliminate malnutrition and taking such an active approach. In theory, this is an attainable goal. Rwanda is an incredibly fertile country, so drought and poor crop yields are not huge issues as in other parts of theworld, like the Sahel. (However, as I write, huge mudslides due to large rainfalls are devastating crops acrossRwanda this week). Furthermore, Rwanda’s community health system is extremely well organized, so community health workers should have no problem teaching the population about food security. 

The reality, of course, is much more complex than rainfalls and soil nutrients. To eliminate malnutrition it is essential to also address endemic issues like class inequality, corruption, alcohol abuse, polygamy, unemployment, and attitudes toward family planning, among many other things. Malnutrition is a problem deeply rooted in poverty. In my limited experience, I have noticed these issues take more than six months to solve.

It’s been a while since I actually blogged about my “work”, so let me describe the nutrition services at my health center as of late:

We have thirteen severely acute malnourished children and twenty two moderately acute malnourished children under the age of five. My health center covers over twenty thousand people, and I would guess the real figure is probably twice that for children under five, to say nothing of infants with chronic malnutrition, malnourished children over the age of five, or malnourished pregnant women.

Severely malnourished children under five years of age who have been identified by community health worker come in (with a caretaker) once a week for growth monitoring, physical checkups, education sessions, and a weekly ration of Ready to Eat Therapeutic Food (RUTF), commonly known by its brand name Plumpy’nut.

While the genius behind Plumpy’nut is that it can be produced almost anywhere in the world with local ingredients, Rwanda’s Ministry of Health and other international donors continue to buy tons of the brand name paste produced in France and import it to community health centers across Africa. When used correctly, treatment should not be needed for more than two consecutive months, but there are cases at my health center that have gone on for six; and a number of children relapse within two years. Although we always explain what RUTF is and why we provide it, many mothers are skeptical, sometimes give it away, and almost always insist their children prefer sosoma: fortified flour. (For further interesting discussion on Plumpy’nut, I’ll direct you here).

Moderately malnourished children under five come in twice a month for growth monitoring, education session, and a two week ration of sosoma. While sosoma is a more culturally appropriate food to give mothers, it often ends up being fed to the whole family, instead of just the malnourished child who desperately needs it. I have personally witnessed many cases where after receiving the fortified flour, a caretaker will go straight to the market and sell it. My coworkers tell me they use the money to buy sorghum beer. 

Despite some challenges, I’m really proud of how much counterpart and I have improved the nutritional services since I first arrived fifteen months ago. Physical examinations actually occur; weekly adherence by patients is higher; more house visits and education sessions are conducted; the health center kitchen gardens are functional; community health workers are leading neighborhood monthly growth monitoring at much higher rates; and all mothers who accept services from the health center adhere to modern birth control methods. Most importantly, I see how much pride my counterpart takes in the new reforms, and I know this will continue long after I leave and/or the government shifts health priorities again.

The government’s pledge to eliminate malnutrition has caused some stir in my neck of the woods. For one, the nursing staff seems slightly more interested in providing necessary antibiotics for sick, malnourished children despite their lack of health insurance. Malnourished children are rarely only malnourished. Nearly all the children come in with parasites and often pulmonary infections. When the children are given antibiotics, the subsequent weight gain can be astounding. Unfortunately, antibiotics are not given out very often.

The local government sector office is also feeling pressure, and more frequently asks for reports from the health center on malnutrition. I could go into how much more unnecessary, redundant paperwork this requires, and how much time away from real patients this takes, but I’ve done enough critiquing for one blog post.

Another exciting result of the Ministry’s pledge: the district hospital finally hired a professional nutritionist to supervise health center programs and take on the most severe malnourished cases that get referred! Although this nutritionist is often tied up in meetings, trainings, and office work, I have been extremely impressed with his rapport and enthusiasm, which seems to have also motivated (and in some cases, intimidated) other staff into being more vigilant.

At my health center, the director sat down with the community health workers and demanded they bring in all malnourished children. The CHWs complied and the numbers in both our severe and moderate malnutrition programs doubled. I was excited to have the influx of cases to treat at the health center (although slightly bitter the CHWs hadn’t listened to me over the last year when I begged them to bring in more cases I knew existed).

My counterpart, the health center nutritionist, however, looked at the new malnutrition cases with agony. “Maybe we shouldn’t record all of them. The Ministry of Health will not be happy with the higher numbers in our monthly reports.”