Darfur and Malnutrition

From the New York Times, comes this article about increased malnutrition rates in Sudan:

"Child malnutrition rates have increased sharply in Darfur, even though it is home to the world’s largest aid operation, according to a new United Nations report.  The report showed that 16.1 percent of children affected by the conflict in Darfur, a vast, turbulent region in western Sudan, are acutely malnourished, compared with 12.9 percent last year. For the first time since 2004, the malnutrition rate, a gauge of the population’s overall distress, has crossed what United Nations officials consider to be the emergency threshold."

For such a short article, there's a lot to chew over.  First, as we've recently learned from the UNAIDS/WHO HIV prevalence fiasco, estimating disease rates in developing countries can be laced with layers of methodological errors.  And, as expected, the prevailing powers in the Sudanese government object to the conclusion. 

Second, the article goes on to say that "the increase [in malnutrition] has occurred despite the efforts of more than 13,000 relief workers in Darfur, who work for 13 United Nations agencies and some 80 private aid groups, and draw from an annual aid budget of about a billion dollars."  This is one of the troubling aspects of aid work in developing countries - it's infrastructurally very difficult to get things done.  Roads don't work, electricity may not be reliable, cell phone service cuts off easily, and so forth.  An MSF friend used to say that even with the resources of armies, it's very difficult to affect things on the ground of a disaster within 24-48 hours.  The necessary items for a particular disaster or locale may not be pre-packaged, roads may be impassable, and airports/runways non-existent.  Extrapolate that to an area as large as Darfur, with such few resources and a consistently violent environment and it may not be that hard to understand why progress isn't being made.

And finally, the article just glances over the whole concept of malnutrition.  But as a field of medicine, it may be as complicated and difficult as any other.  Imagine a child who's malnourished who comes to your clinic.  She's too weak to be febrile, so she may have an underlying infectious cause, but you don't know.  There are no labs available as you're in a conflict zone, so there's no white cell count.  The child may be dehydrated, but without baseline electrolytes giving IV fluids may cause severe pulmonary edema.  Perhaps she has HIV - but she was breast feeding so the current antibody tests may just be the mother's antibodies.  What about TB as a cause for the malnutrition?  Unfortunately, children get extrapulmonary TB more frequently than adults...and moreover, there's no xrays anyway out in the field.  And then you still have to differentiate malaria exposure, kwashiorkor, nephrotic syndrome, etc - all with very limited labs or xrays.

Multiply this by a few hundred children with malnutrition in a conflict zone and one enters the reality of a therapeutic feeding center...and, quite likely, Darfur.